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

 
We decided that the Plan does not have to pay for codes 80307 and G0483 for date of service May 16, 2023. 
 
You asked the Plan to pay for codes 80307 and G0483. 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. 
 
 
 
 
 We find that CPT codes 80307 and G0483 are not supported in the medical record. Specifically, the medical 
records do not include laboratory results for the codes billed. Based on this information, we decided that 
Medicare rules for coverage of codes 80307 and G0483 have not been met. Therefore, we decided that the Plan 
does not have to pay for codes 80307 and G0483 for date of service May 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided May 16, 
223, to June 9, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you are requesting 
reconsideration based on medical necessity for this enrollee and evidence based medical literature that 
substantiate the efficacy of the treatment rendered. The Plan denied your request. The Plan says a PCD coded 
as E0675 is not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided May 16, 223, to June 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oncology second-opinion consultation to be provided 
by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve an oncology second-opinion consultation. You say that the requested 
services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for 
coverage for OON services have not been met. 
 
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 oncology second-opinion consultation to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for repair resin partial maxillary denture base (D5612) 
provided on March 17, 2022. 
 
You asked the Plan to reimburse for the dental services. You say that you submitted your paperwork three 
times. You also say you do not understand why your claim was partially denied for timely filing. 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 Plan's 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 reached the maximum allotted amount with the claim on date of service March 17, 2022. 
Therefore, we decided that the Plan does not have to reimburse for repair resin partial maxillary denture base 
(D5612) provided on March 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft (D4263) for tooth #15 and guided 
tissue regeneration (D4266) for tooth #15 provided on February 9, 2023. 
 
You asked the Plan to pay for the bone replacement graft (D4263) for tooth #15 and guided tissue regeneration 
(D4266) for tooth #15. You say that you say that the office manager at the provider's office advised these 
procedures would be covered 100% by your insurance. The Plan denied your request. The Plan says your 
benefit for the requested item or service has already been exhausted. The Plan also says that you did not contact 
the Plan prior to the date of service to verify benefits and provider eligibility. 
 
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 annual maximum allowable benefit for the requested item or service was exhausted on date of 
service April 21, 2023. Therefore, we decided that the Plan does not have to pay for the bone replacement graft 
(D4263) for tooth #15 and guided tissue regeneration (D4266) for tooth #15 provided on February 9, 2023.  
 
Your complaint about the dishonesty of the providers office manager is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service June 12, 2023, billed 
with codes 87481, 87640, 87653, 87798, 87150, and 87641. 
 
You asked the Plan to pay for the billed testing. The Plan denied your request. The Plan says the codes are not 
separately reportable. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
The file shows that a urinary tract infection panel was provided. We looked at the file and Medicare rules. The 
documentation supports that this panel used the nucleic acid probe technique. There is no evidence that 
multiple procedures, multiple methodologies, or multiple kits were used in this case. As such, a single code 
with one unit of service should be used. Based on this information, we decided that Medicare rules for 
coverage of the testing panel have not been met. Therefore, we decided that the Plan does not have to pay for 
the lab testing billed for date of service June 12, 2023, billed with codes 87481, 87640, 87653, 87798, 87150, 
and 87641.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing (87633) provided on May 10, 2023. 
 
You asked the Plan to pay for procedure code 87633. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the panel testing (87633) provided on May 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 25609 rendered on December 13, 2022. 
 
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 body of the operative report does not state the number of fragments that were repaired with 
internal fixation. 
 
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 25609 is "Open treatment of distal radial intra-articular 
fracture or epiphyseal separation; with internal fixation of 3 or more fragments." 
 
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 the procedure details cite the fracture was identified bilaterally and reduced with fixation completed by a 3-hole standard geminus plate and 
cortical screws, 11mm distally and 10 mm proximally. However, the operative report does not clearly 
document that an internal fixation of 3 or more fragments was performed (despite being noted as intra-
articular.) Therefore, the documentation does not support that CPT 25609: open treatment of distal radial intra-
articular fracture or epiphyseal separation; with internal fixation of 3 or more fragments was performed in this 
case. 
 
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 procedure code 25609 rendered on December 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller 
harness (E2313), expandable controller (E2377), and functional reach/transfer - 30-degree anterior tilt (K0108). 
 
You asked the Plan to pre-approve an electronic connection, expandable controller harness, expandable 
controller, and functional reach/transfer. You say that you would like the documentation provided for the 
requested equipment to be reconsidered, as it is necessary to meet the enrollee's medical and functional needs. 
The Plan denied your request. The Plan says the upgraded electronics and functional reach/transfer are not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an electronic connection, expandable 
controller harness, expandable controller, and functional reach/transfer. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has paraplegia, but is able to feed themself and bathe with modified independence. Our 
reviewer also found that this request is not medically necessary as the enrollee has adequate strength to manage 
standard power drives.  
 
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 electronic connection, expandable controller harness, expandable controller, 
and functional reach/transfer have not been met. Therefore, we decided that the Plan does not have to pre-
approve an electronic connection (E2311), expandable controller harness (E2313), expandable controller 
(E2377), and functional reach/transfer - 30-degree anterior tilt (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99211 rendered on July 13, 2023. 
 
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 Current Procedural Terminology (CPT 99211) remains 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 99211 is "Office or other outpatient visit for the 
evaluation and management of an established patient that may not require the presence of a physician or other 
qualified health care professional." 
 
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 the enrollee was reported to have 
been treated on 7/13/23 in an office visit based on the submitted CPT 99211 code. However, the provided 
documentation did not include a progress note showing evaluation and management of the patient required to 
verify this encounter took place. Therefore, the documentation does not support that CPT 99211 was actually 
performed. 
 
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 procedure code 99211 rendered on July 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and the related 
supply allowance. 
 
You asked the Plan to pre-approve the CGM and related supply allowance. You say that the CGM is medically 
necessary so you can stop poking your fingers. The Plan denied your request. The Plan says the Medicare 
coverage criteria was not met. 
 
The Plan follows 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 pre-approve the CGM and related supply allowance. 
Our reviewer says that the CGM coverage criteria was not met. Our physician reviewer found that the provided 
records in this case do not document the enrollee is insulin treated and they do not document a history of 
problematic hypoglycemia. The records report the enrollee is doing very well with their diabetes. 
 
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 and related supply allowance have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and the related supply 
allowance.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the chiropractic care to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the chiropractic care. You say that you cannot drive 2-3 times a week to the 
provider, and you need transportation, and this service needs to be covered as well.  The Plan denied your 
request. The Plan says the enrollee must get thier care from network providers Usually, the plan wont cover 
care from a provider who doesnt work with the health plan. This means that the enrollee will have to pay the 
provider in full for the services furnished from providers outside of the 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 
the chiropractic care to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided from 
April 18, 2023, to May 8, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the item at issue is not a covered 
benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. The rules also say that a PCD coded 
as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided from April 18, 2023, to May 8, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services billed for dates of service June 15, 
2023, to June 19, 2023. 
 
You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says rules for payment have not been met.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT/HCPCS code. 
 
We find that the home health services at issue do not meet criteria for payment. Specifically, the services have 
been reported without a required G code to represent a visit by the appropriate HH care discipline(s). Based on 
this information, we decided that Medicare rules for coverage of home health services have not been met. 
Therefore, we decided that the Plan does not have to pay for home health services billed for dates of service 
June 15, 2023, to June 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for a specialist office visit and injection provided on 
December 1, 2022. 
 
You asked the Plan to waive the cost for an office visit and injection. You say that you feel this amount is too 
high, you did not know that this provider was out-of-network. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. You have been asked to pay the in-network costs. 
 
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 physician/practitioner services, including doctors office visits, and a 20% coinsurance for 
Medicare Part B drugs. The allowed amount of the injection was $1,350.60, resulting in a $270.12 coinsurance 
($1,350.60 x 20% = $270.12). You have a $35 copayment for a specialist visit ($35 + $270.12 = $305.12).  You have been asked to pay a $305.12 total cost for an office visit and injection. This item/service falls within 
the physician/practitioner services, including doctors office visits, and Medicare Part B drugs 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 cost for a specialist office visit and injection provided on December 1, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported porcelain/ceramic crown (D6058) 
and custom fabricated abutment (D6057). 
 
You asked the Plan to pre-approve abutment supported porcelain/ceramic crown and custom fabricated 
abutment. You say that you believe on the document it appears that it is covered under major restorative 
services. You also say that you believe it should be covered. The Plan denied your request. The Plan says 
implants and related services are not covered by your dental 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. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
abutment supported porcelain/ceramic crown (D6058) and custom fabricated abutment (D6057).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for practitioner services provided on August 21, 2023, billed with procedure code 99213-25.

You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and should be paid. The Plan denied your request. The Plan says documentation does not support the billed code.

The Plan follows Medicare rules. Medicare rules say that visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed.

We asked our coding 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 practitioner services provided. Our reviewer says that documentation does not support the billed code. Our physician reviewer found that in this case, a significant, separately identifiable evaluation and management service was not included in report, and therefore cannot be verified.

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 practitioner services provided have not been met. Therefore, we decided that the Plan does not have to pay for practitioner services provided on August 21, 2023, billed with procedure code 99213-25.