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

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is investigational and experimental. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging showing only modic changes without facet 
degenerative joint disease. The cause of pain is not clear. 
 
   
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628, 64629).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on May 11, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the panel should be billed 
with one unit of one code. 
 
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 the lab panel provided on May 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the bone marrow biopsy and aspirations 
provided on June 16, 2023. 
 
You asked the Plan to waive the copayment for the bone marrow biopsy and aspirations. You say that you were 
advised the payment would only be $150 and you cannot afford to pay more. 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 $390 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
You have been asked to pay a $390 copayment for the bone marrow biopsy and aspirations. 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 waive the copayment for the bone marrow biopsy 
and aspirations provided on June 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair received on October 19, 2022. 
 
You asked the Plan to pay for the wheelchair. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the item received is not a covered benefit in this place of service. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the wheelchair was used in a nursing facility. Therefore, we decided that the Plan does not 
have to pay for the wheelchair received on October 19, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a periodic preventive medicine exam provided on August 8, 2023. 
 
You asked the Plan to pay for the periodic preventive medicine exam. You say that this exam has always been 
covered and you looked at the Plan's guide, which does not show this is not a covered benefit. The Plan denied 
your request. The Plan says that annual comprehensive preventative visits are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the Plan has not provided a Plan rule to substantiate their denial. 
Therefore, we decided that the Plan has to pay for a periodic preventive medicine exam provided on 
August 8, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the problem focused limited oral evaluation (D0140) provided on June 
19, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. The Plan denied 
your request. The Plan says that your benefit for the requested item or service has already been exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pay for the problem focused limited oral evaluation 
(D0140) provided on June 19, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73030 provided on July 23, 2023. 
 
You asked the Plan to pay for procedure code 73030. 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. 
 
We find that CPT code 73030 is not supported in the medical record. Specifically, this code has a status 
indicator of Q1 and was billed on the same date of service as code 99284 which has a status indicator of V. 
This code is not separately payable. Based on this information, we decided that Medicare rules for coverage of 
procedure code 73030 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 73030 provided on July 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the office visit. You say that you are requesting reconsideration for denied 
services with supporting documentation. The Plan denied your request. The Plan says the enrollee must receive 
their care from a network provider (for more information about this, see Section 2 of Chapter 3). In most cases, 
care the enrollee receives from an out-of-network provider (a provider who is not part of the plans network) 
will not be 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the office visit to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
July 20, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service July 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the high strength lightweight wheelchair (E1088) 
provided on May 4, 2023, an out-of-network (OON) provider.  
 
You asked the Plan to reimburse you for the wheelchair. You say that you had fractured your left hip. The 
wheelchair is a convenience and makes it easier for visits to doctors and getting around. If it is normally an 
item for reimbursement, you believe you should get something. The Plan denied your request. The Plan says enrollees must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 
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 reimburse you 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. A onetime exception was granted for reimbursement of the shower seat that was 
purchased April 15, 2023. Wheelchairs are a rental only item. Therefore, reimbursement for purchase is not 
covered. We found no exception that would require the Plan to reimburse you for these items/services. 
Therefore, we decided that the Plan does not have to reimburse you for the high strength lightweight 
wheelchair (E1088) provided on May 4, 2023, an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 23, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
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 the laboratory services rendered on June 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit, and the shaving of a lesion 
provided on June 19, 2023. 
 
You asked the Plan to pay for a new patient office visit, and the shaving of a lesion. You say that you tried to 
get into an in-network provider. 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 a new patient office 
visit, and the shaving of a lesion provided on June 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sales tax (S9999) for the traction equipment purchased on 
August 26, 2022. 
 
You asked the Plan to pay for the sales tax. You say that this should be covered. The Plan denied your request. 
The Plan says Medicare does not cover sales tax. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not reimburse separately for sales 
tax.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the sales tax have not been met. Therefore, we decided that the Plan does not have to pay for the 
sales tax (S9999) for the traction equipment purchased on August 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 24, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was 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 the laboratory services 
provided on July 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extra-large heating pads (E0210). 
 
You asked the Plan to pre-approve the heating pads. You say that this is urgently needed because your shoulder 
is swollen. You have another one but that one is for your stomach. The Plan denied your request. The Plan says 
there is no documentation to show that the approved standard pad does not meet the enrollee's needs. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have standard heating pads (E0210) which was approved November 8, 2023. The 
provided standard heating pads (E0210) serves the same purpose as the requested heating pads. Therefore, we 
decided that the Plan does not have to pre-approve extra-large heating pads (E0210).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code P9603 billed for January 30, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code P9603 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code P9603 is travel allowance one way in connection with 
medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; 
prorated miles actually travelled. 
 
We find that CPT code P9603 is not supported in the medical record. Specifically, the documentation is not 
clear regarding which professional collected the specimen. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code P9603 billed for January 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the unspecified anesthesia procedure (D9999), the deep 
sedation first 15 minutes (D9222), and the deep sedation - each additional 15 minutes (D92223). 
 
You asked the Plan to pre-approve the unspecified anesthesia procedure (D9999), the deep sedation first 15 
minutes (D9222) and the deep sedation - each additional 15 minutes (D92223). You say that you need just had 
wisdom teeth taken out two months ago and the anesthesia had approved them. You say having a tooth 
extracted without anesthesia will be very painful. The Plan denied your request. The Plan says the services are not covered benefits. 
 
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 unspecified anesthesia procedure 
(D9999), the deep sedation first 15 minutes (D9222), and the deep sedation - each additional 15 minutes 
(D92223) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve the unspecified anesthesia procedure (D9999), the deep sedation first 15 minutes (D9222), and the 
deep sedation - each additional 15 minutes (D92223),
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the debridement provided on August 25, 
2023. 
 
You asked the Plan to waive the copayment for the debridement. You say that the copayment is too much 
money for you too pay. 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 debridement. 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 waive the copayment for the debridement provided on 
August 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on April 27, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration stating the 
services were not authorized by a PCP are you are resubmitting the claim with medical 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 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 office visit provided 
on April 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 26, 2023. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. 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 July 26, 2023.