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

 
We decided that the Plan does not have to pay for procedure code 74018 billed for date of service January 5, 
2023. 
 You asked the Plan to pay for procedure code 74018. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 74018 is bundled into payment for code 74022. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 74018 
is a column II code to column I code 74022. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 74018 billed for date of service January 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 23, 2023. 
 
You asked the Plan to pay for the lab services. You say that these services 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 the lab services provided 
on January 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the eyeglasses (V2020, V2781, V2750) purchased 
on December 16, 2022, from an out-of-network provider.  
You asked the Plan to reimburse you for the eyeglasses. You say that you want the Plan to reimburse you for 
the eyeglasses. The Plan denied your request. The Plan says vision benefits received out-of-network are not 
covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when you utilize an in-network provider. 
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse 
you for the eyeglasses (V2020, V2781, V2750) purchased on December 16, 2022, from an out-of-network 
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 
January 9, 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 January 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle test strips (A4253). 
 
You asked the Plan to pre-approve FreeStyle test strips. You say that you have not gotten any test strips. You 
also say that you called the pharmacy and were advised that the Plan is not covering them. The Plan denied 
your request. The Plan says only the preferred brand products listed in the EOC are covered.  
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DMEPOS to only those 
preferred brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary 
(including non- preferred) DME products or brands. The rules also say that a health plan must disclose to its 
enrollees, in clear accurate terms, the benefits offered under a plan, including applicable conditions and 
limitations associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for FreeStyle test strips. Therefore, we decided that the Plan does not have to pre-approve FreeStyle test strips 
(A4253).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz. 
 
You asked the Plan to pre-approve Supartz. You say that the requested Supartz is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Synvisc, Synvisc-One, Orthovisc, or 
Monovisc first.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Supartz. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee has not trialed one 
viscosupplemental treatment such as Synvisc, Synvisc-One, Orthovisc, or Monovisc.  Step therapy, as outlined 
by the Plan, requires that one of these be trialed first. The documentation does not outline contraindications or 
reasons these medications were not considered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Supartz have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Supartz.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot return to home 
setting being on this level oxygen. The Plan denied your request. The Plan says the enrollee is receiving the 
care needed in the current hospital and there is no need to transfer to the LTACH at this time. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Contour Next EZ meter. 
 
You asked the Plan to pre-approve a Contour Next EZ meter. You say that you are requesting a Contour Next 
meter (non-preferred) The Plan denied your request. The Plan says only the preferred brand products listed in 
the EOC are covered.  
  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for a Contour Next EZ meter. Therefore, we decided that the Plan does not have to pre-approve a Contour Next 
EZ meter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80307 and G0482 for date of service 
October 27, 2022. 
 
You asked the Plan to pay for procedure codes 80307 and G0482. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says code 80307 is a duplicate. Code G0482  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also 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 find that CPT codes 80307 and G0482 are not supported in the medical record. Specifically, code 80307 is 
a duplicate claim in which was paid on November 5, 2022. 
 
the file includes evidence that the services at issue were reimbursed by the Plan on November 5, 2022. 
Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that 
the billed items/services were provided twice on the same date. Therefore, code 80307 is not payable as billed. 
In addition, the date of service on the claim does not align with the records; therefore, code G0482 is not 
supported. Based on this information, we decided that Medicare rules for coverage of procedure codes 80307 
and G0482 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
80307 and G0482 for date of service October 27, 2022.
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 you are appealing the denial of IRF. The Plan denied 
your request. The Plan says  that medically necessity has not been met. 
 
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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
 and benefit from  the intensive rehabilitation therapy program provided in an IRF. 
 
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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder detect test (0012M) provided on December 1, 
2022. 
 
You asked the Plan to pay for the Cxbladder detect test. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder detect test have not been met. Therefore, we decided 
that the Plan does not have to pay for the Cxbladder detect test (0012M) provided on December 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiologic examination of the hand provided on  
December 6, 2022. 
 
You asked the Plan to pay for a radiologic examination of the hand. The Plan denied your request. The Plan 
says the services were not urgent or emergent and the services could have been rendered by a Plan participating 
provider. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a radiologic examination of the hand provided on  
December 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown - porcelain fused to high noble metal (D2750) 
Tooth #8 and post and core in addition to crown, indirectly fabricated (D2952) Tooth #8. 
 
You asked the Plan to pre-approve the dental services. You say that you should not have to pay for the billed 
services because you had a crown put on and it fell off the next day. Therefore, you had to return to the office 
and have it fixed. The Plan denied your request. The Plan says your benefit for the requested item or 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. This benefit includes the 
requested D2750 and D2952 but each is limited to one per 60 floating months. 
 
  We looked at the file, the Plans rules, and Medicares rules. You previously received covered crown - 
porcelain/ceramic (D2740) Tooth #8 on July 12, 2022, and core buildup, including any pins when required 
(D2950) Tooth #8 on June 20, 2022. Therefore, these services were exhausted. Therefore, we decided that the 
Plan does not have to pre-approve crown - porcelain fused to high noble metal (D2750) Tooth #8 and post and 
core in addition to crown, indirectly fabricated (D2952) Tooth #8.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 37248 and 75726 rendered on December 30, 
2022. 
 
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 support the services 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. 
 
In this case, the CPT Code Manual definition of the denied codes is:  
CPT 37248: 
 
Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and 
radiological supervision and interpretation necessary to perform the angioplasty within the same vein; initial 
vein 
 
CPT 75726: 
 
Angiography, visceral, selective or supraselective (with or without flush aortogram), radiological supervision 
and interpretation 
 
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 based on the operative records 
provided, there is no documentation that CPT 37248 was rendered in this case on this date of service. The 
records do not document that the vessel was "stretched to a larger diameter, allowing a more normal outflow of 
blood through the area" as required for proper documentation for CPT 37248. In terms of CPT 75726, the 
records do not support this code as a separate and distinct procedure from CPT 37244. The embolization codes 
(CPT 37244) include all associated radiological supervision and interpretation, intraprocedural guidance and 
road-mapping, and imaging necessary to document completion of the procedure. 
 
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 procedure codes 37248 and 75726 rendered on December 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 38630 and 37607 rendered on January 4, 
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 service is not supported without the required documentation. 
 
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 the denied codes is: 
 
CPT 38630: 
 
Creation of arteriovenous fistula by other than direct arteriovenous (AV) anastomosis (separate procedure); 
nonautogenous graft (eg, biological collagen, thermoplastic graft) 
 
 
 CPT 37607: 
 
Ligation or banding of angioaccess arteriovenous fistula 
 
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 CPT code 36830 is not supported. 
The procedure report describes using a graft to bypass an aneurysm, not to create an AV fistula. This is not the 
most descriptive code for this procedure. CPT code 37607 is not supported. The procedure report does not 
mention ligating or banding the angioaccess of the AV fistula. The vessels were clamped and an anastomosis 
was performed, however, the ligation is not mentioned. The procedure report does not support that the 
procedures in question were performed. 
 
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 procedure codes 38630 and 37607 rendered on January 4, 2023.
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 
January 3, 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 January 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99215 billed for date of service December 
19, 2022. 
 You asked the Plan to pay for procedure code 99215. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 99215 is bundled into payment for code 77293, 77300, 77301, 
and 77338. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99215 
is a column II code to column I codes 77293, 77300, 77301, and 77338. This claim has not been billed with an 
appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 99215 billed for date of 
service December 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on December 
17, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on December 17, 2022.