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

 
We decided that the Plan does not have to pay for drug testing services (procedure code G0482) rendered on 
May 3, 2023. 
 
You asked the Plan to pay for the services. You say that you are requesting that the claim be reviewed and 
reprocessed for payment. The Plan denied your request. The Plan says ordering a multi-class panel of definitive 
(confirmation) urine drug tests that are not used in clinical management, exceeds the needs of the enrollee. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the definitive testing of multiple drug classes goes beyond the number required for this enrollee who 
is being prescribed only one pain medication. There was no indication from the documentation that the enrollee 
showed signs of drug abuse/misuse or additional drugs that might warrant this extensive definitive drug testing 
panel. Therefore, the enrollee did not require 15-21 drug class testing.  
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services (procedure code G0482) rendered on May 3, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 76775 and 93978 billed for date of service 
April 28, 2023. 
 You asked the Plan to pay for procedure codes 76775 and 93978. You say that the services were billed 
correctly and should be paid. The Plan denied your request. The Plan says payment for code 76775 is bundled 
into payment for code 93978. CPT code 93978 was denied because there is a more appropriate CPT code that 
should be used to bill for the service provided. 
 
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 93978 is duplex scan of aorta, inferior vena cava, iliac 
vasculature, or bypass grafts; complete study. In addition, we have confirmed we have confirmed that code 
76775 is a column II code to column I code 93978; however, code 76775 was billed with a modifier. 
 
We asked our coder 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 procedure codes 76775 and 93978. Our 
reviewer found that the procedure report does not include sufficient documentation to support code 93978, as 
there is no documentation to support that a complete study was performed. In addition, code 76775 is not 
supported as a separately identifiable procedure. The documentation submitted does not contain a description 
of this procedure, and therefore neither the procedure code nor modifier can be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 93978 and 76775 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 76775 and 93978 billed for date of service April 28, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for continuous glucose monitor (CGM) 
device (A4239) provided August 2, 2023. 
 
You asked the Plan to pay for the CGM supplies. You say that kindly accept your request and reprocess your 
claim. The Plan denied your request. The Plan says the items were provided from a supplier who is not enrolled 
in Medicare as a durable medical equipment supplier. 
 
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 the supply allowance for continuous 
glucose monitor (CGM) device (A4239) provided August 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81279, 81270, 81339, 81221).  
You asked the Plan to pre-approve genetic testing. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that genetic testing is covered when medically 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 genetic testing. Our reviewer says that 
the requested testing is not medically necessary. Our physician reviewer found there has been no testing for 
BCR-ABL. Further, genotyping is considered medically necessary in the initial diagnostic work-up of BCR-
ABL negative, JAK2-negative adults in individuals for whom PV is a consideration. Without BCR-ABL 
testing having been performed, the additional tests are 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 genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genetic testing (81279, 81270, 81339, 81221).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the lab testing provided on September 22, 
2023. 
 
You asked the Plan to waive the copayment for the lab testing. You say that you want to appeal the amount 
being charged. 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 $40 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $40 copayment for the lab testing. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and 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 lab testing provided on September 22, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the outpatient surgery provided on August 
22, 2023, to September 05, 2023. 
 
You asked the Plan to reduce the copayment for the outpatient surgery. You say that your surgery was done at 
an ambulatory surgical center, so your copayment should be $200. 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 $350 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
You have been asked to pay a $350 copayment for the outpatient surgery. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 reduce the copayment for the outpatient surgery provided 
on August 22, 2023, to September 05, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the negative pressure wound therapy 
provided on September 01, 2023. 
 
You asked the Plan to waive the copayment for the negative pressure wound therapy. You say that you should 
not have to pay this copayment because your wound was only redressed. 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 $350 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
You have been asked to pay a $350 copayment for the negative pressure wound therapy. This item/service falls 
within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers 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. However, since the allowed amount is less than the standard copayment, you only owe $183.69. 
Therefore, we decided that the Plan does not have to waive the copayment for the negative pressure wound 
therapy provided on September 01, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic supplies provided on July 4, 2023. 
 
You asked the Plan to pay for the diabetic supplies. You say that you disagree with the denial of payment and 
have submitted documentation for review. The Plan denied your request. The Plan says you are not enrolled in 
Medicare as a durable medical equipment supplier. Therefore, the claim remains denied. 
 
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 the diabetic supplies provided on July 4, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on September 18, 
2023 
 
You asked the Plan to pay for the dental service. You say that you got a letter saying your previous dentist was 
no longer in-network. You say that you have a hole in your tooth. You also say that this was necessary to 
determine the depth and severity of the hole. The Plan denied your request. The Plan says your benefit for this 
service has already been exhausted.  
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for this service was exhausted on date of service November 21, 2022. Therefore, we 
decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on September 18, 2023
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on August 21, 2023. 
 
You asked the Plan to pay for the wound care supplies. You say that these are a separately billable expense and 
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 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(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 wound care supplies provided on August 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service April 1, 
2023, to April 22, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that the claim should be paid. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes.   
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service April 1, 2023, to April 22, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on October 5, 2022, to 
October 11, 2022. 
 
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim is not supported by the records provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
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 home health services. Our reviewer says that the records 
do not support the billed services. Our reviewer found the physician order does not include documentation to 
support the need for further home health services. The records are not fully legible and do not support the 
diagnosis codes billed. 
 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for home health services provided on October 5, 2022, to October 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
September 25, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. 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 $35 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $35 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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. However, since the allowed amount is less than the 
standard copayment, you only owe $22.71. Therefore, we decided that the Plan does not have to waive the 
copayment for the specialist office visit provided on September 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral first x-ray (D0220), intraoral each additional x-ray 
(D0230), diagnostic consultation (D9310), and cone beam computed tomography (CT) capture and 
interpretation of the jaw (D0364) provided on September 29, 2023. 
 
You asked the Plan to pay for the dental services. You say that your regular dentist referred you to this dentist 
for two bad teeth. The Plan denied your request. The Plan says your benefit for the intraoral first x-ray 
(D0220), intraoral each additional x-ray (D0230) has already been exhausted. The Plan also says that 
diagnostic consultation (D9310), and cone beam computed tomography (CT) capture and interpretation of the 
jaw (D0364) are not covered under this benefit. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for intraoral first x-ray (D0220), intraoral each additional x-ray (D0230) was exhausted on 
date of service March 14, 2023. The record also shows that diagnostic consultation (D9310), and cone beam 
computed tomography (CT) capture and interpretation of the jaw (D0364) are excluded from this benefit. 
Therefore, we decided that the Plan does not have to pay for intraoral first x-ray (D0220), intraoral each 
additional x-ray (D0230), diagnostic consultation (D9310), and cone beam computed tomography (CT) capture 
and interpretation of the jaw (D0364) provided on September 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient visit provided on August 23, 
2023. 
 
You asked the Plan to waive the copayment for the outpatient visit. You say that you dont feel that you or your 
insurance owes for this visit because nothing was done. 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 $10 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $10 copayment for the outpatient visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 outpatient visit provided on August 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9338 billed for date of service January 25, 
2023. 
 
You asked the Plan to pay for procedure code S9338. You say that the claim should be paid. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes.   
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9338 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9338 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9338 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9338 billed for date of service January 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor provided on August 01, 2023. 
 
You asked the Plan to pay for a continuous glucose monitor. You say that this was medically necessary, please 
see records for review. 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 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(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 continuous glucose monitor provided on August 01, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will lose bodily function and will not be 
able to return to baseline. The Plan denied your request. The Plan says the enrollee does not meet the criteria 
for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.