Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on July 18, 2023, billed with 
procedure codes Q4010 and 29075. 
 
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 code Q0092 is not recognized, the claim was 
returned. A corrected claim must be submitted with an alternate code. 
 
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 practitioner services provided have 
been met. Specifically, a corrected claim must be submitted with an appropriate procedure code. Therefore, we 
decided that the Plan does not have to pay for practitioner services provided on July 18, 2023, billed with 
procedure codes Q4010 and 29075.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the foot surgery provided on June 27, 
2023. 
 
You asked the Plan to reduce the copayment for the foot surgery. You say that you developed an infection after 
your surgery and had to have the procedure re-done. Therefore, you feel you should not have to pay 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 $200 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
You have been asked to pay a $200 copayment for the foot 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 foot surgery provided on June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on September 06, 
2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services rendered were 
medically necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for subsequent nursing 
facility care provided on September 06, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an i-Factor peptide enhanced bone graft. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is limited published, large-scale, 
long-term peer-reviewed literature that shows the requested i-Factor graft to be an effective and/or safe 
treatment for the noted pathology. Further studies are needed to corroborate that the requested allograft would be as safe or better than standard autograft procedures. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested i-Factor peptide enhanced bone graft is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an i-Factor peptide enhanced bone graft.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service August 24, 
2023.  
 You asked the Plan to pay for procedure code 86077. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service August 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulatory infusion pump (E0781) provided May 2, 
2023. 
 
You asked the Plan to pay for the ambulatory infusion pump. You say that please reprocess for payment as this 
was medically necessary. The Plan denied your request. The Plan says the claim needs to be resubmitted with 
corrected "TO DOS" (date of service) in order to pay claim correctly.  

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 E0781 is ambulatory infusion pump, single or multiple 
channels, electric or battery operated, with administrative equipment, worn by patient. 
 
We find that CPT code E0781 is not supported in the medical record. Specifically, it's not appropriate to use a 
single date of service for a rented item of durable medical equipment. Based on this information, we decided 
that Medicare rules for coverage of the ambulatory infusion pump have not been met. Therefore, we decided 
that the Plan does not have to pay for the ambulatory infusion pump (E0781) provided May 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for guided tissue regeneration of natural teeth (dental code 
D4266) provided on June 26, 2023. 
 
You asked the Plan to pay for D4266. You say that this was critical to the success of your implant. The Plan 
denied your request. The Plan says code D4266 should only be used with natural teeth, and there is another 
dental code that should be used. 
 
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 D4266 is guided tissue regeneration, natural teeth  
resorbable barrier  per site. 
 
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 D4266. Our reviewer says that this code does not meet criteria for payment. Our reviewer found the record describes tissue regeneration for dental implants, for which 
there is a more appropriate procedure code that should have been used. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of D4266 have not been met. Therefore, we decided that the Plan does not have to 
pay for guided tissue regeneration of natural teeth (dental code D4266) provided on June 26, 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 denied your request. 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 enrollee has 
multiple sclerosis, and is able to groom and feed themself. Our reviewer also found that the enrollee has 
adequate strength to manage standard power drives. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lift shift/transfer chair. 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary for a history of repeated 
falls. The Plan denied your request. The Plan says the notes do not have any documentation that a standard 
patient lift will not meet the enrollee's needs. 
 
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 the item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee is noted to have a history of falling and is noted to be in a wheelchair during the 
physical examination. However, there is insufficient information regarding the enrollees level of function with 
regards to performing transfers and mobility and if the enrollee can independently perform transfers or not. There is limited physical examination provided, including motor strength of the upper and lower limbs. The 
enrollee is not noted to have a significant neuromuscular disease or osteoarthritis of the knee or hip joints that 
would necessitate this medical equipment. 
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a lift shift/transfer chair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 12, 2023. 
 
You asked the Plan to pay for laboratory services. You say that this was necessary to treat the patient, please 
see records and reprocess. 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 laboratory services 
provided on July 12, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the medical supplies and injections on 
January 24, 2023, to August 29, 2023. 
 
You asked the Plan to waive the cost share for the medical supplies and injections. You say that you were 
under the impression that these services were 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a 5% coinsurance for Medicare-covered items for durable medical equipment. Enrollees must pay a 
5% coinsurance for Medicare Part B chemotherapy rugs, associated administration services and all other 
Medicare Part B drugs. 
 
The enrollee has been asked to pay a 5% coinsurance for each medical supply and injection. This item/service 
falls within the durable medical equipment (DME) and related supplies and Medicare Part B prescription drugs 
benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract 
with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
The total amount you owe is $834.81, which is 5% coinsurance of the allowed amount for each item. 
Therefore, we decided that the Plan does not have to waive the cost share for the medical supplies and 
injections on January 24, 2023, to August 29, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the additional therapy is medically 
necessary. The Plan denied your request. The Plan says the requested therapy services are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the records do not demonstrate that the unique skills of a professional 
therapist are required to provide treatment and that the services can be safely and effectively performed only by 
a therapist, or by or under the supervision of a therapist. The requested services are not part of a maintenance 
program. The requested additional therapy sessions do not require ongoing skilled professional therapy. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 12 physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87481, 87500, 87640, 87653, 87798) provided 
on August 11, 2023. 
 
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 claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.   
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for lab services (87481, 87500, 87640, 87653, 87798) provided on August 11, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Ranibizumab injections provided on 
August 21, 2023. 
 
You asked the Plan to waive the coinsurance for Ranibizumab injections. You say that you should not have this 
large coinsurance on this service. 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 prescription drugs. 
 
You have been asked to pay 20% coinsurance for Ranibizumab injections. This item/service falls within the 
Medicare Part B prescription 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 $465.58 ($232.79 coinsurance x 2 injections = $465.58). 
Therefore, we decided that the Plan does not have to waive the coinsurance for Ranibizumab injections 
provided on August 21, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 provided on May 18, 2023. 
 
You asked the Plan to pay for procedure code 99285. You say that the medical records support the billing of 
procedure code 99285. The Plan denied your request. The Plan says the medical records do not support the 
billing of procedure code 99285. 
 
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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 code 99285. Our reviewer says that the medical records do not support the billing of procedure code 99285. Our reviewer found the enrollee presented to the 
emergency department (ED) with flank pain. Vitals included low grade fever, and workup revealed positive 
urinalysis for infection, leukocytosis, and nephrolithiasis bilaterally on ultrasound. She was discharged home 
with opioids for pain without any plans for invasive treatment or management. The documentation from this 
encounter included an appropriate history and examination, however, it does not support a high level of 
decision-making to help justify the submitted code, 99285 as the enrollee was stable and uncomplicated.  
 
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 code 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285 provided on May 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for interrogation device evaluation provided on July 16, 2023, 
by an out-of-network (OON) provider.  
 You asked the Plan to pay for interrogation device evaluation. You say that the service was medically 
necessary. The Plan denied your request. The Plan says that their original decision to deny payment was 
correct. 
 
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 interrogation device evaluation provided on July 
16, 2023, by an OON provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on August 03, 
2023. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you dont understand why you are 
being billed as you went to an in-network facility. 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 $150 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $150 copayment for an ultrasound. 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. However, since the allowed amount is less than the standard 
copayment, you only owe $141,51. Therefore, we decided that the Plan does not have to waive the copayment 
for an ultrasound provided on August 03, 2023.