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

 
We decided that the Plan does not have to pay for the chest x-ray provided on April 5, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the chest x-ray. You say that you are appealing the denial with supporting 
documentation. The Plan denied your request. The Plan says the service was not authorized. 
 
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 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. 
Therefore, we decided that the Plan does not have to pay for the chest x-ray provided on April 5, 2023, by an 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiofrequency ablation provided on June 14, 2022. 
 
You asked the Plan to pay for the radiofrequency ablation. You say that you are requesting reconsideration of 
the denied claim. 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 radiofrequency 
ablation provided on June 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each cataract removal procedure provided 
on April 27, 2023, to May 11, 2023. 
 
You asked the Plan to waive the copayment for each cataract removal procedure. You say that you think that 
this is considered cosmetic surgery. 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 $240 
copayment for in-network Medicare-covered surgery or other services provided at an ambulatory surgical 
center.  
You have been asked to pay a $240 copayment for each cataract removal procedure. This item/service falls 
within the in-network Medicare-covered surgery or other services provided at an ambulatory surgical center 
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 amount you owe is $480 ($240 copayment x 2 services = $480). Therefore, we decided that the Plan does 
not have to waive the copayment for each cataract removal procedure provided on April 27, 2023, to May 11, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that you would like reconsideration because the 
requested raised toilet seat is medically necessary. The Plan denied your request. The Plan says this item is not 
a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a back brace provided on April 10, 2023. 
 
You asked the Plan to waive the coinsurance for a back brace. You say that you were not informed that there 
would be a cost share. 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 covered prosthetic devices and supplies, including braces. 
 
You have been asked to pay 20% coinsurance for a back brace. This item/service falls within the covered 
prosthetic devices and supplies, including braces 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 $94.80 ($473.98 allowed amount x 20% = $94.80 rounded up). Therefore, we decided that the Plan does not have to waive the coinsurance for a back 
brace provided on April 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on July 14, 2022. 
 
You asked the Plan to pay for the nursing facility care. You say that you are requesting reconsideration of the 
denied claim. 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 nursing facility care 
provided on July 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
March 28, 2023. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you should not be 
held responsible for the copayment. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for ambulance services. 
 
You have been asked to pay a $250 copayment for the ambulance transportation. This item/service falls within 
the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
ambulance transportation provided on March 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgently needed services provided on 
May 13, 2023. 
 
You asked the Plan to waive the copayment for the urgently needed services. You say that you disagree with 
the copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for urgently needed services. 
 
You have been asked to pay a $45 copayment for the urgently needed services. This item/service falls within 
the urgently needed services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the urgently 
needed services provided on May 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on April 19, 2023. 
 
You asked the Plan to pay for the home visit. You say that the assisted living facility is responsible to obtain 
prior authorization for all of their patients. 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 home visit provided 
on April 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine (9) additional months for the home ventilator 
(E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that the requested ventilator is medically necessary. 
The Plan denied your request. The Plan says the requested ventilator is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the ventilator. Our physician reviewer 
found the device is being used in the average volume-assured pressure support (AVAPS) mode, which can be 
provided with bilevel positive airway pressure (BiPAP). The records do not show that BiPAP has been tried 
and failed as an outpatient.  Medicare does not cover a home ventilator when used at settings that can be 
provided with BiPAP. The Plan has approved the ventilator for 3 months which allows time for transition to 
BiPAP. The denial is upheld. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve nine (9) additional months for the home ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87899 and 87900 billed for date of service 
June 9, 2022. 
 
You asked the Plan to pay for procedure codes 87899 and 87900. You say that these services were necessary 
and are supported as billed. The Plan denied your request. The Plan says these services are not supported in the 
medical record. 
 
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 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 procedure codes 87899 and 87900. Our reviewer says that 
these codes are not supported. Our reviewer found the laboratory report does not include sufficient 
documentation to confirm CPT code 87899 has been performed. Per the code definition, the lab analyst 
performs the technical lab test to analyze for an infectious agent by immunoassay with direct optical, meaning 
visual, observation. This procedure cannot be verified in documentation submitted. In addition, the laboratory 
report does not include sufficient documentation to confirm CPT code 87900 has been performed. Per the code 
definition, the lab analyst measures a patient's susceptibility or resistance to drugs aimed at a virus. The test 
predicts the behavior of the phenotype based on comparing patient data to regularly updated genotypic 
bioinformatics. The clinician can use the information to help in deciding which drugs to prescribe. This 
procedure cannot be verified in documentation submitted. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87899 and 87900 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 87899 and 87900 billed for date of service June 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine (9) additional months for the home ventilator 
(E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that the requested ventilator is medically necessary. 
The Plan denied your request. The Plan says the requested ventilator is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the ventilator. Our physician reviewer 
found the device is being used in the average volume-assured pressure support (AVAPS) mode, which can be 
provided with bilevel positive airway pressure (BiPAP). The records do not show that BiPAP has been tried 
and failed as an outpatient. Medicare does not cover a home ventilator when used at settings that can be 
provided with BiPAP. The Plan has approved the ventilator for 3 months which allows time for transition to 
BiPAP. The denial is upheld. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve nine (9) additional months for the home ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services (28285) provided on December 28, 
2022. 
 
You asked the Plan to pay for the surgical assistant services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 28285. 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 surgical assistant services have not been met. Therefore, we decided that the Plan does not have to pay for 
surgical assistant services (28285) provided on December 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry and tandem mass spectrometry 
(83789-59) provided April 5, 2023. 
 
You asked the Plan to pay for procedure code 83789. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 83789 is bundled into payment for code G0480. 
 
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 83789 
is a column II code to column I code G0480. This claim has not been billed with an appropriate modifier to 
bypass the edit. This code is included in Healthcare Common Procedure Coding System (HCPCS) code G0480; 
therefore, it cannot be separately reimbursed. This code is not separately reimbursed when billed for specimen 
validity testing on urine specimens utilized for drug testing. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for the mass spectrometry 
and tandem mass spectrometry (83789-59) provided April 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a biopsy (20245) provided on April 7, 2023.

You asked the Plan to pay for the biopsy. You say that this service was medically necessary. The Plan denied your request. The Plan says coverage criteria has 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 code.

In this case, the CPT Code Manual definition of code 20245 is biopsy, bone, open; deep (eg, humeral shaft, ischium, femoral sharft) in addition to femoral fracture treatment for service provided.

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 biopsy. Our reviewer says that the documentation does not support the billed code. Our reviewer found the operative report describes left femur fracture treatment, and left femur biopsy. Records do not show this procedure was separate from code 27245.

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 biopsy have not been met. Therefore, we decided that the Plan does not have to pay for a biopsy (20245) provided on April 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injections provided on March 14, 2023, to March 20, 
2023, by an OON provider.  
 
You asked the Plan to pay for the injections. You say that you are appealing the denial with supporting 
documentation. The Plan denied your request. The Plan says the service was not authorized. 
 
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 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. 
Therefore, we decided that the Plan does not have to pay for the injections provided on March 14, 2023, to 
March 20, 2023, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313) and an expandable controller 
(E2377). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the upgraded electronics are not covered as there is not a medical need to 
control the requested power options through the joystick. 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found a group 3 power wheelchair (PWC) can be covered if the medical necessity for a 
PWC is met and if the disorder causing the mobility limitation is a neurological condition, myopathy or 
congenital skeletal deformity. The enrollee also must require a drive control interface, power tilt or a power 
recline seating system and if there has been a specialty evaluation that was performed by a licensed/certified 
medical professional, such as a physical or occupational therapist. An expandable controller is an electronic 
system that is capable of accommodating one or more additional features and can operate 3 or more powered 
seating options. The requested electrical accessories are not medically necessary as the enrollee does have use 
of the upper extremity and can operate and control the power options using the switches that are included in the 
basic wheelchair. There is not a medical need for the upgraded electronics. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection between wheelchair controller and two or more power 
seating system motors (E2311), a harness (E2313) and an expandable controller (E2377).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 17, 2023. 
 
You asked the Plan to pay for lab services. You say that the ordering physician is responsible for obtaining 
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 lab services provided on 
March 17, 2023.