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

 
We decided that the Plan does not have to pay for procedure code 75630 billed for date of service December 
29, 2022. 
 
You asked the Plan to pay for procedure code 75630. The Plan denied your request. The Plan says payment for 
code 75630 is bundled into payment for code 93460. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 75630 
is a column II code to column I code 93460. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 75630 billed for date of service December 29, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service January 24, 
2023.  
 
You asked the Plan to pay for procedure code 99232. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99232 is bundled into payment for code 99233. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99232 
is a column II code to column I code 99233 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 99232 billed for date of service January 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve VenaSeal sclerotherapy of the distal left great 
saphenous vein (GSV). 
 
You asked the Plan to pre-approve VenaSeal sclerotherapy of the distal left GSV. You say that the requested 
VenaSeal sclerotherapy of the distal left GSV is medically necessary. The Plan denied your request. The Plan 
says the enrollee does not meet criteria for the requested VenaSeal sclerotherapy of the distal left GSV. 
 
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 VenaSeal sclerotherapy of the distal left 
GSV. Our reviewer says that the enrollee does not meet criteria for the requested VenaSeal sclerotherapy of the 
distal left GSV. Our physician reviewer found the record indicates that the enrollee has untreated proximal 
saphenous vein reflux. The elements of the coverage criteria are not satisfied. The requested service is not 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of VenaSeal sclerotherapy of the distal left GSV have not been met. Therefore, we 
decided that the Plan does not have to pre-approve VenaSeal sclerotherapy of the distal left great saphenous 
vein (GSV).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the excision of breast lesion (19125) provided on November 
30, 2022. 
 
You asked the Plan to pay for the excision of breast lesion (19125). You say that the services were ordered by 
the in-network surgeon and provided at the in-network facility. You say that the services were provided in the 
interest of the enrollee's safety and additional benefits should be released. The Plan denied your request. The 
Plan says an assistant surgeon cannot be paid for this procedure. 
  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 19125. 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 
excision of breast lesion (19125) have not been met. Therefore, we decided that the Plan does not have to pay 
for the excision of breast lesion (19125) provided on November 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the AVISE CTD testing provided on August 29, 2022.  
 
You asked the Plan to pay for the AVISE CTD testing. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this testing was 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 pay for the AVISE CTD testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the AVISE Connective Tissue Disease (CTD) test uses autoantibody, erythrocyte-bound C4d (EC4d) and B-cell-bound C4d (BC4d) levels to aid in diagnoses of systemic lupus 
erythematosus (SLE), other CTDs and fibromyalgia. We evaluated the utility of the AVISE CTD test in 
predicting SLE disease development and damage progression. The AVISE CTD test can aid in SLE evaluation 
by predicting SLE disease development and future damage progression. In this case the enrollee did not have a 
diagnosis of SLE, CTD or fibromyalgia. The review has determined that the items/services at issue in this case 
were not medically reasonable or necessary. 
 
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 AVISE CTD testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the AVISE CTD testing provided on August 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20526 billed for date of service December 
20, 2022.  
 
You asked the Plan to pay for procedure code 20526. You say that the medical records support procedure code 
20526-LT and 20526-RT. 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 cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 20526 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 20526 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 20526 billed for date of service December 20, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 324 units of procedure code A0425 billed for date of service 
January 30, 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 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 can be paid with an appropriate modifier, on separate lines, when the MAI value is 1.  
 
In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 1. You billed 324 units of 
this code on one line, exceeding the MUE. 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 324 
units of procedure code A0425 billed for date of service January 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95861 billed for date of service July 14, 
2022.  
 
You asked the Plan to pay for procedure code 95861. You say that the claim is billed correctly and should be 
paid. 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 95861 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 95861 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 95861 billed for date of service July 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on December 29, 2021. 
 
You asked the Plan to pay for wound care supplies. You say that these supplies are a separately billable 
expense that do not require authorization. The Plan denied your request. The Plan says that unauthorized, out-
of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for wound care supplies 
provided on December 29, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for Fluorodeoxyglucose F-18 FDG provided on December 2, 2021. 
 
You asked the Plan to pay for Fluorodeoxyglucose F-18 FDG. The Plan denied your request. The Plan says that 
this service does not meet the coverage requirements in the applicable Local Coverage Determination (LCD) or 
National Coverage Determination (NCD). Related services performed in connection with the denied procedure 
are also not covered.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a Medicare rule, a Plan rule or a coding 
rule to substantiate their denial. Therefore, we decided that the Plan has to pay for Fluorodeoxyglucose F-18 
FDG provided on December 2, 2021.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Kerecis omega 3, skin substitute (Q4158) and 
application of skin substitute graft (15275). 
 You asked the Plan to pre-approve the skin graft procedure. You say that please reconsider authorization for 
the enrollee to receive the Kerecis graph. The Plan denied your request. The Plan says Omega 3 is not 
separately payable and is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The Plan's medical policy shows Omega 3 is not separately payable. 
Based on this information, we decided that Medicare rules for coverage of the skin graft procedure have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the Kerecis omega 3, skin 
substitute (Q4158) and application of skin substitute graft (15275).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on January 19, 2023. 
 
You asked the Plan to pay for a home visit. You say that the service was medically necessary. 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 home visit provided on 
January 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM) 
(95250). 
 
You asked the Plan to pre-approve a Freestyle Libre 3 CGM. You say that you disagree with the denial and 
request reconsideration. The Plan denied your request. The Plan says the Freestyle Libre 3 is a newer device 
that uses a smartphone exclusively and has no stand-alone receiver option. The reason this device is not 
covered is because smartphones are not classified as DME devices by Medicare. 
 The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.  
 
We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM) (95250).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Wegovy. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. 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 Wegovy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the TissueCypher Barrett's esophagus assay provided on 
January 10, 2023.  
 
You asked the Plan to pay for the TissueCypher Barrett's esophagus assay. You say that this testing is 
medically necessary. The Plan denied your request. The Plan says this assay for determining the risk of 
progression from Barrett's esophagus to high grade dysplasia or cancer remains unproven.  
 
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 pay for the TissueCypher Barrett's esophagus assay. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found TissueCypher is not the standard of care and is not medically 
necessary. 
 
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 TissueCypher Barrett's esophagus assay have not been met. Therefore, we 
decided that the Plan does not have to pay for the TissueCypher Barrett's esophagus assay provided on January 
10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 8, 2022. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the member has other insurance as primary. In order to process 
this claim we need an Explanation of Benefits from the primary insurance carrier. We have tried to obtain the 
Explanation of Benefits but it is not yet received.  
 
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 tried to 
obtain the Explanation of Benefits (EOB). As the secondary insurer, the Plan cannot be held responsible for the 
office visit until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan 
does not have to pay for an office visit provided on June 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99309 for date of service December 21, 
2022. 
 
You asked the Plan to pay for procedure code 99309. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not payable. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for procedure code 99309 for date of service 
December 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on December 21, 2022. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration for the denied 
payment. 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 the office visit provided 
on December 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve coronary computed tomography angiography (CCTA). 
 
You asked the Plan to pre-approve CCTA. You say that your right coronary artery is still blocked. The Plan 
denied your request. The Plan says you are asymptomatic and there is no indication for this imaging.  
The Plan follows Medicare rules. Medicare rules state that CCTA tests are never covered for screening (in the 
absence of signs, symptoms, or disease). 
 
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 CCTA. Our reviewer says that you do 
not meet criteria for this testing. Our physician reviewer found you are asymptomatic. As a result, at this time 
CCTA imaging would not be considered medically reasonable and necessary in your clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CCTA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve coronary computed tomography angiography (CCTA).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital observation 
provided on April 11, 2023. 
 
You asked the Plan to waive the copayment for the outpatient hospital observation. You say that this should 
have been a specialist office visit 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 $300 
copayment for in-network outpatient hospital observation. 
 
You have been asked to pay a $300 copayment for the outpatient hospital observation. This item/service falls 
within the in-network outpatient hospital observation 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. The record shows this claim was approved and you are 
responsible for the cost share amount. However, since the allowed amount is less than the standard copayment, 
you only owe $115.18. Therefore, we decided that the Plan does not have to waive the copayment for the 
outpatient hospital observation provided on April 11, 2023.