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

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service May 11, 
2023.  
 
You asked the Plan to pay for procedure code 88341. You say that you disagree with the Plan's denial. 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 15 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 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service May 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair (E2602, E0971, K0195, K0003). 
 
You asked the Plan to pre-approve a wheelchair. You say that the item is necessary. The Plan denied your 
request. The Plan says the enrollee's current wheelchair is less than 5 years old and there is no information 
showing the equipment is damaged. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement due to wear is not covered during 
the reasonable useful lifetime of the equipment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a wheelchair (E2602, E0971, K0195, K0003).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Vabysmo (J2777). 
 You asked the Plan to pre-approve Vabysmo. You say that Vabysmo is a medical necessity for the enrollee. 
The Plan denied your request. The Plan says step-therapy rules for coverage of Vabysmo have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Vabysmo. Our reviewer says that 
treatment with Vabysmo is not medically reasonable and necessary in this case. Our physician reviewer found 
that the Plan requires a trial of drug bevacizumab before they will approve the requested drug. In this case, the 
enrollee has not tried and failed the required drug. There is no documentation provided indicating that the 
Plans required drug would likely be less effective and/or likely have adverse effects 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 Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Vabysmo (J2777).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for closed treatment of distal phalangeal fracture, finger or 
thumb; without manipulation, each rendered on February 10, 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) code 26750-54 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 26750 is "Closed treatment of distal phalangeal fracture, 
finger or thumb; without manipulation, each." 
 
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 there is no documentation that 
would support CPT 26750 with the 54 modifier. 
 
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 closed treatment of distal phalangeal fracture, finger or thumb; without manipulation, each 
rendered on February 10, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy (PT) and a home health 
aide. 
 
You asked the Plan to pre-approve home health services. You say that you have a broken hip and cannot leave 
your house. The Plan denied your request. The Plan says you have a PCP who is responsible for providing your 
routine health care needs and overseeing your care. Your PCP gave you a slip for outpatient care instead of 
home care. 
 
The Plan must follow Medicare rules. Medicare rules say that you have a PCP who is responsible for providing 
your routine health care needs and overseeing your care. If you need certain types of covered services or 
supplies from network providers, you must get approval in advance from your PCP (such as giving you a 
referral). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the records show that your PCP disagrees 
with your request and has referred you for outpatient care. The EOC confirms that your PCP is responsible for 
overseeing your care and you must get approval from your PCP for all services. Therefore, we decided that the 
Plan does not have to pre-approve home health physical therapy (PT) and a home health aide.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services billed with procedure codes 67228-RT, 
93886-59, 93890-59, 93892-59, 92202-LT, 92202-RT, and 99214 provided on April 12, 2023, by an out-of-
network (OON) provider.  
 
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 codes 67228, 93886, 93890, and 93892 were not 
pre-authorized and were received from an out of network provider, code 92202 exceeded the MUE, and code 
99214 was not billed with an appropriate modifier. 
 
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 rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2. The rules say that the global surgery package 
of a minor procedure with a 0- or 10-day global period includes preoperative evaluation and management (EM) 
services on the day of surgery. Modifier "-25" is used to facilitate billing of evaluation and management 
services on the day of a procedure for which separate payment may be made. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. In 
addition, code 99214 is not payable as it was not reported with the required modifier, and 92202 denied 
correctly as the MUE value for this code is 1 and the MAI value is 2. This claim was inappropriately billed 
with 2 units of this code, specifically 92202-RT and 92202-LT. Therefore, we decided that the Plan does not 
have to pay for practitioner services billed with procedure codes 67228-RT, 93886-59, 93890-59, 93892-59, 
92202-LT, 92202-RT, and 99214 provided on April 12, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided April 17, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that the DecisionDx-SCC test is a covered 
Medicare benefit. The Plan denied your request. The Plan says this test is not medically reasonable or 
necessary 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. Per DEX Diagnostics Exchange, DecisionDx-SCC is noncovered by 
Medicare. In addition, per the Plan's policy Proprietary Laboratory Analyses (PLA) Codes, 0315U is listed as a PLA noncovered due to investigational status. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for the DecisionDx-SCC test (0315U) provided April 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care services (99232) billed for date of service 
January 27, 2023. 
 
You asked the Plan to pay for hospital care services. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported 
together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that R73.09 has an Excludes1 note in relation to E11.10 and E11.65. This 
means that the diagnosis codes cannot be reported together. Based on this information, we decided that the 
Medicare billing rules for hospital care services have not been met. Therefore, we decided that the Plan does 
not have to pay for hospital care services (99232) billed for date of service January 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the semi-electric hospital bed (E0260). 
 
You asked the Plan to pre-approve the semi-electric hospital bed. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the item is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that you do not need this item. Our physician reviewer found the documentation does not specify 
why the is item is 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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the semi-electric hospital bed (E0260).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the drug injection provided on June 13, 
2023. 
 
You asked the Plan to waive the coinsurance for the drug injection. You say that you want to appeal this 
coinsurance amount. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B drugs. 
 
You have been asked to pay 20% coinsurance for the drug injection. This item/service falls within the 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. The total you owe is $216.53 ($1,082.63 allowed amount x 20% coinsurance = $216.53). 
Therefore, we decided that the Plan does not have to waive the coinsurance for the drug injection provided on 
June 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular stimulator billed with code E0745 for 
April 3, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that modifier -RR must be billed when DME is to be 
rented. 
 
We looked at the file and Medicare rules. The file shows that code E0745 was not billed with the required -RR 
modifier. 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 pay for the neuromuscular stimulator billed 
with code E0745 for April 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy provided from October 19, 2022, to 
November 4, 2022. 
 You asked the Plan to pay for infrared therapy. You say that you were informed that the enrollee's coverage for 
acupuncture is 100% after a copayment. The Plan denied your request. The Plan says that their original 
decision to deny payment is correct. 
 
The Plan must follow Medicare rules. Medicare rules say that infrared therapy is not a covered service.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of infrared therapy have not been met. Therefore, we decided that the Plan does not have to pay for 
infrared therapy provided from October 19, 2022, to November 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for swimming classes provided on January 1, 2023 
for the 2022 benefit year. 
 
You asked the Plan to reimburse you for the swimming classes. You say that the swimming classes you had 
were for aerobic exercise and to be able to swim laps on a regular basis is good cardio exercise and easier on 
your joints. The Plan denied your request. The Plan says a membership for swimming does not meet criteria for 
reimbursement of a wellness allowance benefit.  
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
 The Plans rules for coverage of gym benefits have not been met because a membership for swimming does not 
meet criteria for reimbursement of a wellness allowance benefit. Therefore, we decided that the Plan does not 
have to reimburse you for swimming classes provided on January 1, 2023 for the 2022 benefit year.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array (63650) and implantable neurostimulator electrode (L8680). 
 
You asked the Plan to pre-approve the implantable neurostimulator device. You say that this is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the records do not show evidence of a 
psychological evaluation. 
 The Plan follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation when certain 
criteria are met. 
 
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 implantable neurostimulator device. 
Our reviewer says that the requested implantable neurostimulator device is not medically necessary. Our 
physician reviewer found the provided documentation does not indicate a final determination has been 
documented in the psychological evaluation certifying that the enrollee is appropriate for the implantable 
neurostimulator device. Therefore, the reviewer found that the requested implantable neurostimulator device is 
not medically reasonable or necessary at this time. 
 
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 implantable neurostimulator device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array (63650) and implantable neurostimulator electrode (L8680).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (36415, 83036) provided on October 22, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
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 36415, & 83036 are not supported in the medical record. Specifically, the collection 
date documented in the records (October 21, 2022) does not match the date of service billed. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (36415, 83036) provided on October 22, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Botox (J0585). 
 You asked the Plan to pre-approve Botox. You say that Botox is a medical necessity for the enrollee. The Plan 
denied your request. The Plan says step-therapy rules for coverage of Botox have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Botox. Our reviewer says that treatment 
with Botox is not medically reasonable and necessary in this case. Our physician reviewer found that the Plan 
requires a trial of drug Xeomin before they will approve the requested drug. In this case, the enrollee has not 
tried and failed the required drug. There is no documentation provided indicating that the Plans required drug 
would likely be less effective and/or likely have adverse effects 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 Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Botox (J0585).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the fitbit and glasses. 
 
You asked the Plan to pay for the fitbit and glasses. You say that the glasses should have been covered under 
the medical benefit allowing the fitbit to be covered under the wallet benefit. The Plan denied your request. The 
Plan says that the wallet benefit has been exhausted. 
 
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. The Plan didnt provide any reasoning why the glasses were processed under the 
wallet benefit instead of the medical benefit and/or anything showing that these were not Medicare-covered 
glasses after cataract surgery. If the glasses were covered under the medical benefit as requested, the allowance 
for the wallet benefit would not have been exhausted. Therefore, we decided that the Plan has to pay for the 
fitbit and glasses.  
 
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 pay for a crown (D2740) and core buildup (D2950) for tooth #18 
provided by an out-of-network provider on January 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are requesting the claim be paid on time. 
The Plan denied your request. The Plan says the denial of payment for these services is correct, because the 
provider did not submit any narrative or x-ray information to support the need for the dental services. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the dental services have been met. 
Specifically, the documentation shows the Plan made multiple attempts requesting x-rays from the out-of-
network provider and x-rays were never sent. Therefore, we decided that the Plan does not have to pay for a 
crown (D2740) and core buildup (D2950) for tooth #18 provided by an out-of-network provider on January 13, 
2023.