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

 
We decided that the Plan does not have to pay for the epidural injection (62323) provided on August 23, 2023. 
 
You asked the Plan to pay for the epidural injection. You say that this claim was coded correctly. The Plan 
denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the service at issue was reimbursed by 
the Plan on September 12, 2023. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed service was provided twice on the same date. Based on this information, we decided that the Medicare rules for the epidural injection have not been met. Therefore, we 
decided that the Plan does not have to pay for the epidural injection (62323) provided on August 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service September 27, 2023. 
 
You asked the Plan to pay for the billed testing. The Plan denied your request. The Plan says the claim for this 
molecular pathology testing did not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the billed testing have 
not been met. Therefore, we decided that the Plan does not have to pay for the lab testing billed for date of 
service September 27, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes J1200, J1885, J2765, 93005, 85025, 84484, 
& 80053 provided on October 1, 2023. 
 
You asked the Plan to pay for procedure codes J1200, J1885, J2765, 93005, 85025, 84484, & 80053. You say 
that these services were medically necessary. The Plan denied your request. The Plan says the claim cannot be 
paid as billed. 
 
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 J1200, J1885, J2765, 93005, 85025, 84484, & 80053 are not supported in the medical 
record. Specifically, the billed codes have a status indicator of N and are packaged with another service billed 
(99284). Based on this information, we decided that Medicare rules for coverage of procedure codes J1200, 
J1885, J2765, 93005, 85025, 84484, & 80053 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes J1200, J1885, J2765, 93005, 85025, 84484, & 80053 provided on October 1, 
2023.
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), and expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, expandable controller harness, and expandable 
controller. The Plan says although there are three approved power options on this wheelchair (tilt, recline and 
elevating leg rests), there is not a medical need to control these 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 an electronic connection, expandable 
controller harness, and expandable controller. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found 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. Our 
reviewer also found that 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 an electronic connection, expandable controller harness, and expandable 
controller have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic 
connection (E2311), expandable controller harness (E2313), and expandable controller (E2377).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction (92015) provided on September 19, 2023. 
 
  You asked the Plan to pay for an eye refraction. You say that you have cataracts and went in for your pre-
surgery examination. You also say that the provider had to determine how your lenses are handling light in 
order to correct your vision problem. The Plan denied your request. The Plan says the services are not covered 
by Medicare and not covered under any condition by the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for an eye refraction (92015) provided on September 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral complete series set of dental x-rays (D0210) 
provided on October 2, 2023. 
 
You asked the Plan to pay for intraoral complete series set of dental x-rays. You say that this should be 
covered. The Plan denied your request. The Plan says this is not a covered service. 
 
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 pay for intraoral 
complete series set of dental x-rays (D0210) provided on October 2, 2023.
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), and expandable controller (E2377).  
 
You asked the Plan to pre-approve an electronic connection, expandable controller harness, and expandable 
controller. You say that you are appealing on the grounds that Medicare has reviewed and approved this 
request. The Plan denied your request. The Plan says although there are three requested power options (tilt, 
recline and elevating leg rests), there is not a medical need to control these 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 an electronic connection, expandable 
controller harness, and expandable controller. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found 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. Our 
reviewer also found that 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 an electronic connection, expandable controller harness, and expandable 
controller have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic 
connection (E2311), expandable controller harness (E2313), and expandable controller (E2377).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99236) 
rendered on January 25, 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 records do not indicate that the enrollee was admitted and discharged on the same date. 
 
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 99236 is "Hospital inpatient or observation care, for the 
evaluation and management of a patient including admission and discharge on the same date, which requires a 
medically appropriate history and/or examination and high level of medical decision making. When using total 
time on the date of the encounter for code selection, 85 minutes must be met or exceeded." 
 
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 documentation does 
not support that admission and discharge happened on the same date. Although the records support a medically 
appropriate history and/or examination, the documentation do not sufficiently support a high level of medical 
decision making as the patient was stable, with ruled out acute coronary syndrome or any other severe acute 
condition and was only planned to do stress test.  
 
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 evaluation and management services (procedure code 99236) rendered on January 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 6, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the core buildup, including any pins when required 
(D2950 x4), retainer crown - porcelain/ceramic (D6740 x1), and pontics - porcelain/ceramic (D6245 x3). 
 
You asked the Plan to pre-approve the dental services represented by codes D2950 x4, D6740 x1, and D6245 
x3. You say that you are asking to reprocess the pre-authorization per the clinicals provided. The Plan denied 
your request. The Plan says your benefit for the requested retainer crown and pontics has already been 
exhausted. The Plan also says that dental code D2950 is not a covered expense under the dental plan. 
 
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, the requested service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the core 
buildup, including any pins when required (D2950 x4). 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested services was exhausted on the appealed claim. Therefore, we decided that 
the Plan does not have to pre-approve the retainer crown - porcelain/ceramic (D6740 x1), and pontics - 
porcelain/ceramic (D6245 x3).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a transthoracic echocardiogram (TTE) 
provided on September 07, 2023. 
 
You asked the Plan to waive the copayment for a transthoracic echocardiogram (TTE). You say that the 
provider did not advise you of any out-of-pocket expense. 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 each in-network Medicarecovered diagnostic radiology service other than CT scans. 
 
You have been asked to pay a $250 copayment for a transthoracic echocardiogram (TTE). This item/service falls within the each in-network Medicarecovered diagnostic radiology service other than CT scans 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 a transthoracic echocardiogram (TTE) provided 
on September 07, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent inpatient or observation care (99233) provided 
from April 5, 2023, to April 10, 2023, by an out-of-network (OON) provider.  
 You asked the Plan to pay for inpatient or observation care. You say that the medically necessary care was 
provided on an emergent basis. The Plan denied your request. The Plan says rules for payment for out-of-
network 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider at issue in this case is not a network provider with the Plan. 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 inpatient or observation care. Our reviewer says that the available medical record 
does not support that the services at issue were provided on an emergent basis. Our physician reviewer found 
that the enrollee was seen by an out-of-network doctor in the hospital from April 5, 2023, to April 10, 2023, for 
atrial fibrillation with rapid ventricular rate. Notes from the above dates describe the enrollee's vitals as stable 
with controlled rate and no other acute or emergent condition requiring care. The enrollee was already 
medically controlled, and follow-up care during these dates does not appear to be emergent. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient or observation care have not been met.  
 
The Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item/service at issue. We found no exception that would 
require the Plan to pay for inpatient or observation care. Therefore, we decided that the Plan does not have to 
pay for subsequent inpatient or observation care (99233) provided from April 5, 2023, to April 10, 2023, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diabetic supplies provided on June 3, 
2023, and September 23, 2023. 
 
You asked the Plan to waive the copayment for the diabetic supplies. You say that you do not agree with the 
billed amount that you owe for the items you received. 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% 
copayment for Medicare-covered equipment and supplies.  
 
  You have been asked to pay a total of $94.54 for the diabetic supplies.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
June 3, 2023 Diabetic supplies $236.34 20% $47.27 
September 23, 2023 Diabetic supplies $236.34 20% $47.27 
TOTAL:    $94.54 
 
This item/service falls within the durable medical equipment (DME) and related supplies 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 diabetic supplies provided on June 3, 2023, and 
September 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensity-modulated and image-guided radiation 
therapies. 
 
You asked the Plan to pre-approve intensity-modulated and image-guided radiation therapies. You say that that 
intensity-modulated radiation therapy is not experimental.  In general, intensity-modulated radiation therapy 
can be considered medically necessary when supported by a dosimetric rationale showing a clinically 
meaningful reduction in normal tissue exposure and/or target coverage. However, the specific need for 
intensity-modulated radiation therapy in this case is not supported with a treatment-plan comparison or any 
records specifically describing why intensity-modulated radiation therapy would be needed. The Plan denied 
your request. The Plan says the requested treatment is a medical necessity for the enrollee. 
 
the requested treatment is experimental/investigational for the enrollee's condition. Therefore, we decided that 
the Plan does not have to pre-approve intensity-modulated and image-guided radiation therapies.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full cost for an emergency room visit and self-administered 
drugs provided on July 8, 2023. 
 
You asked the Plan to pay the full cost for an emergency room visit and self-administered drugs. You say that 
this should be fully covered. 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 $110 
copayment for each emergency room visit. The rules also say that Medicare Part B generally does not pay for 
self-administered drugs.  
 
You have been asked to pay a $110 copayment for an emergency room visit. This service falls within the 
emergency 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. You are also responsible for the full cost of the 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 pay the full cost for an emergency room visit and self-administered drugs 
provided on July 8, 2023.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: 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 attendant control (E2331). 
 
You asked the Plan to pre-approve an electronic connection, expandable controller harness, expandable 
controller, and attendant control. You say that Medicare has reviewed, approved, and deemed this equipment 
medically necessary. The Plan denied your request. The Plan says although there are three requested power 
options (tilt, recline and elevating leg rests), there is not a medical need to control these power options through 
the joystick. The Plan also says per Medicare rules, an attendant control cannot be covered in addition to a 
beneficiary-operated 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 an electronic connection, expandable 
controller harness, expandable controller, and attendant control. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found 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. Our reviewer found additionally, the 
requested attendant controls do not have a medical purpose in this case. 
 
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 attendant control 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 
attendant control (E2331).