Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code B4199 for date of service April 17, 2023, to April 21, 
2023. 
 
You asked the Plan to pay for code B4199. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services billed are 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 B4199 is parenteral nutrition solution; compounded 
amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any 
strength, over 100 grams of protein - premix. 
 
We find that CPT code B4199 is not supported in the medical record. Specifically, the claim form submitted did not include a National Drug Code (NDC) number for the billed parenteral nutrition solution. This means 
code B4199 is not payable as billed. Based on this information, we decided that Medicare rules for coverage of 
code B4199 have not been met. Therefore, we decided that the Plan does not have to pay for code B4199 for 
date of service April 17, 2023, to April 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on March 3, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that you are appealing the denial with supporting 
records. The Plan denied your request. The Plan says this test is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for CxBladder are 
not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Cxbladder test have not been met. Specifically, this test is not covered by Medicare. Therefore, 
we decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on March 3, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Freestyle Libre 3. 
 
You asked the Plan to pre-approve the Freestyle Libre 3. You say that you are appealing the denied CGM. The 
Plan denied your request. The Plan says that the requested CGM is a non-preferred brand, and only Lifescan or 
Roche is the preferred brand. Also, the Freestyle Libre 3 is not eligible for reimbursement by Medicare. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section.  
 
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 does not say in clear and accurate terms 
that a Lifescan and Roche is the preferred brand for a CGM. 
 
We looked at your contract with the Plan. We did not see where the contract says that therapeutic CGMs are 
limited to only Lifescan and Roche. The Plan contract clearly says that therapeutic CGMs are limited to Abbott 
and Lifescan brand products which Freestyle Libre 3 is a CGM of Abbot. This means that the Plan did not 
substantiate their denial reason for the Freestyle Libre 3. The Freestyle Libre 3 is now a covered device, as it 
has been assigned the covered code of E2103 as of June 15, 2023. Based on this information, we decided that 
Medicare rules for coverage of the Freestyle Libre 3 have been met. Therefore, we decided that the Plan has to 
pre-approve a Freestyle Libre 3. 
 
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: Unfavorable

 
We decided that the Plan does not have to pay more for a diagnostic cast, extractions, periodontal scaling and 
root planing, implants, panoramic x-ray, comprehensive oral evaluations, bitewing x-rays, intraoral x-rays, 
surgical extractions, endosteal implants, cleanings, and periodic oral evaluation (D0470, D7210, D4342, 
D6010, D0330, D0150, D4342, D0272, D0220, D7210, D6010, D1110, D0120) provided from May 23, 2022, 
to October 17, 2022. 
 
  You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. Coverage for the diagnostic casts, extractions, periodontal scaling and root planing, and implants 
denied correctly as they do not fall within your dental 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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for a diagnostic cast, extractions, periodontal 
scaling and root planing, implants, panoramic x-ray, comprehensive oral evaluations, bitewing x-rays, intraoral 
x-rays, surgical extractions, endosteal implants, cleanings, and periodic oral evaluation (D0470, D7210, D4342, 
D6010, D0330, D0150, D4342, D0272, D0220, D7210, D6010, D1110, D0120) provided from May 23, 2022, 
to October 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that you have plantar fasciitis and need these inserts. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that you need these foot orthotics. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110). 
 
You asked the Plan to pre-approve D5110. You say that you lost your denture while moving. 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 26, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the insertion of a permanent pacemaker (33206) and the 
unlisted procedure, cardiac surgery (33999) provided on December 6, 2022. 
 
You asked the Plan to pay for procedure codes 33206 and 33999. You say that you are appealing the denial. 
The Plan denied your request. The Plan says the billed codes are 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 33206 is the insertion of new or replacement of 
permanent pacemaker with transvenous electrode(s); atrial. The definition of CPT code 33999 is an unlisted 
procedure, cardiac surgery. 
 
 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 codes 33206 and 33999. Our reviewer says that 
the billing of the procedure codes is not supported. Our reviewer found that the procedure report for date of 
service December 6, 2022, does not include documentation of insertion of new or replacement of permanent 
pacemaker (33206).  The procedure report describes catheter ablation. The reviewer was unable to cite the 
report, as this procedure was not found in the medical record. The procedure report does not include 
documentation of an unlisted cardiac procedure (33999). When reporting an unlisted procedure, documentation 
should include a description of the unlisted procedure. This procedure cannot 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 33206 and 33999 have not been met. Therefore, we decided 
that the Plan does not have to pay for the insertion of a permanent pacemaker (33206) and the unlisted 
procedure, cardiac surgery (33999) provided on December 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray and crown (D0220, D2740) provided on 
March 29, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
intraoral x-ray and crown (D0220, D2740) provided on March 29, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasounds and an MRI performed from 
December 6, 2021, to December 15, 2021. 
 
You asked the Plan to waive the copayment for ultrasounds and an MRI. You say that you disagree with the 
cost share applied. 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 each diagnostic radiology service, including MRI and ultrasounds.  
 
You have been asked to pay 112.71 coinsurance for ultrasounds and an MRI. This total includes $55.74 
coinsurance, which is 20% of the allowed amount for ultrasounds (287.70 allowed x 20% = $55.74) and $56.97 
coinsurance, which is 20% of the allowed amount for an MRI ($284.83 allowed x 20% = $56.97). This 
item/service falls within the outpatient diagnostic tests 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 ultrasounds and an MRI performed from December 6, 2021, to December 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit provided 
on September 16, 2022, to September 30, 2022. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) visit. You say that you have $0 
copayment for primary doctor and specialist visits. 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 $20 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $20 copayment for each physical therapy (PT) visit. This item/service falls 
within the outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. The total copayment you owe is $120 for PT visits ($20 per visit x 6 visits = 
$120). Therefore, we decided that the Plan does not have to waive the copayment for each physical therapy 
(PT) visit provided on September 16, 2022, to September 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Kneehab XP Conductive Garment (E0731) and supplies 
(A4595) provided on March 24, 2023. 
 
You asked the Plan to pay for a Kneehab XP Conductive Garment and supplies. You say that these items were 
medically necessary. The Plan denied your request. The Plan says these items are not covered for the enrollee's 
condition. 
 
The Plan follows Medicare rules. Medicare rules say that  a conductive garment (E0731) used with a 
Transcutaneous Electrical Nerve Stimulators (TENS) unit is rarely reasonable and necessary, but is covered 
only if all of the conditions listed in the rules section are met. Reimbursement for supplies is contingent upon 
use with a covered TENS unit. 
 
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 a Kneehab XP Conductive Garment and 
supplies. Our reviewer says that the items at issue were not medically necessary. Our physician reviewer found 
the provided records document the enrollee does have a large treatment area, but they do not clearly document 
that the enrollee cannot manage without the conductive garment because there is such a large area or so many 
sites to be stimulated and the stimulation would have to be delivered so frequently that it is not feasible to use 
conventional electrodes, adhesive tapes, and lead wires. The provided records do not document the enrollee 
cannot manage without the conductive garment for the treatment of chronic intractable pain because the areas 
or sites to be stimulated are inaccessible with the use of conventional electrodes, adhesive tapes, and lead 
wires. The records do not document the enrollee has a documented medical condition, such as skin problems, 
that preclude the application of conventional electrodes, adhesive tapes, and lead wires. The records do not 
document the enrollee requires electrical stimulation beneath a cast to treat chronic intractable pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Kneehab XP Conductive Garment and supplies have not been met. Therefore, 
we decided that the Plan does not have to pay for a Kneehab XP Conductive Garment (E0731) and supplies 
(A4595) provided on March 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation and intraoral x-ray (D0230, D0140, 
D0220) provided on December 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited 
oral evaluation and intraoral x-ray (D0230, D0140, D0220) provided on December 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on July 18, 2022, to August 4, 
2022. 
 
You asked the Plan to pay for the home health services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as the 
rendering provider is not enrolled with Medicare. 
 
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 home health services provided on July 
18, 2022, to August 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that you need this to help monitor the enrollee's diabetes. 
The Plan denied your request. The Plan says the enrollee does not meet the medical criteria for a CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on November 29, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that your 
husband fell and you had no way to lift him so you had no choice but to call the rescue to help. You also say 
that he was not transported to the hospital. The Plan denied your request. The Plan says these services are not a 
covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on November 29, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on November 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 11044, 76000-59 and 25609 billed for date 
of service February 10, 2023.  
 
You asked the Plan to pay for procedure codes 11044, 76000-59 and 25609. You say that this was billed 
correctly. The Plan denied your request. The Plan says these services are not supported in the records. 
 
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 state that providers may bill 
services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.   
 In this case, the CPT Code Manual definition of code 11044 is debridement, bone (includes epidermis, dermis, 
subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less. The definition of 76000 is 
fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional time. The 
definition of 25609 is open treatment of distal radial intra-articular fracture or epiphyseal separation; with 
internal fixation of 3 or more fragments. 
 
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 codes 11044, 76000-59 and 25609. Our reviewer 
says that these codes are not supported in the records. Our reviewer found the operative report does not include 
documentation of the depth and surface area of the debridement, meaning code 11044 cannot be verified. 
While code 76000 was billed with modifier -59, the radiology service would be included in the primary 
procedure, as both procedures were performed same anatomical location. An intra-articular or extra-articular 
procedure cannot be verified to support code 25609 as the submitted operative report only documents a "distal 
radial fracture."  
 
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 11044, 76000-59 and 25609 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 11044, 76000-59 and 25609 billed for date of 
service February 10, 2023.