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

 
We decided that the Plan does not have to pay for the telehealth services (99441) provided on August 25, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
payable in this case. 
 
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 99441 is "Telephone evaluation and management service 
by a physician or other qualified health care professional who may report evaluation and management services 
provided to an established patient, parent, or guardian not originating from a related E/M service provided 
within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest 
available appointment; 5-10 minutes of medical discussion". 
 
We find that CPT code 99441 is not supported in the medical record. Specifically, the records shows that the telehealth visit originated from a related E/M service provided within the previous 7 days, as both visits were 
billed with diagnosis code D46.9. 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 the telehealth 
services (99441) provided on August 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on August 10, 
2023. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process.  
 We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this 
information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on 
August 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), a cleaning (D1110), the 
surgical placement of implant body (D6010) for tooth #12 and #18, a bone graft (D6104) for tooth #12, and the 
removal of interim implant (D6198) for tooth #19 provided by an out-of-network provider on May 31, 2022, 
June 6, 2022, July 14, 2022, and April 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are providing documentation so the Plan 
can pay for the dental services. The Plan denied your request. The Plan says the denial of payment for the 
surgical placement of implant body and the bone graft is correct because they are not covered by the Plan. The 
claims for May 31, 2022, and June 6, 2022, were filed 1 year after the date of service. 
 
Medicare rules say that claims for services furnished on or after January 1, 2010, must be filed no later than 
one calendar year after the date of service. 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. 
 
The record shows that a claim for limited oral evaluation (D0140), a cleaning (D1110), and the removal of an 
interim implant (D6198) for tooth #19 provided on May 31, 2022, and June 6, 2022, was not filed until June 
27, 2023. This means that more than one calendar year from the date of service had passed before a claim was 
filed. Though the Plan offers a dental benefit in excess of Medicare coverage, the surgical placement of implant 
body and the bone graft are not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pay for a limited oral evaluation (D0140), a cleaning (D1110), the surgical placement of 
implant body (D6010) for tooth #12 and #18, a bone graft (D6104) for tooth #12, and the removal of interim 
implant (D6198) for tooth #19 provided by an out-of-network provider on May 31, 2022, June 6, 2022, July 14, 
2022, and April 13, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing provided on September 28, 2023. 
 
You asked the Plan to pay for the lab testing. The Plan denied your request. The Plan says that the testing was 
not medically necessary. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
The services at issue were provided by a contract provider. The file does not show that the Plan provided notice 
that the lab testing would not be covered. Under Medicare rules, this means the lab testing is considered 
approved by the Plan. Therefore, we decided that the Plan has to pay for the lab testing provided on September 
28, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of extra skin and tissue (15830). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the removal of extra skin and tissue is not medically necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer 
found the record indicates that you have undergone panniculectomy and abdominoplasty. The record indicates 
that the requested procedure is to revise the closure. The record provided does not document that the scar is 
functionally limiting or has caused intertrigo. The requested procedure is to reshape and adjust normal 
structures of the body to enhance the visual appearance and is therefore, cosmetic. The record provided does 
not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 
The elements of the coverage criteria are not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the removal of extra skin and tissue (15830).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that the enrollee has severe obesity and alveolar 
hypoventilation. You say that the enrollee arterial blood gas levels are high, and they have tried and failed other 
reactive airway disease therapies. The Plan denied your request. The Plan says a home ventilator is not medically necessary for this patient because their needs can be met with an alternative device such as a BiPAP 
device with average volume-assured pressure support (AVAPS). 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the ventilator. Our physician reviewer 
found there is no diagnosis of chronic obstructive pulmonary disease (COPD), thoracic restrictive disease, or 
neuromuscular disease. The enrollee was recently hospitalized with pneumonia, and an arterial blood gas was 
consistent with acute on chronic hypercarbic respiratory failure. The PaCO2 improved on bilevel positive 
airway pressure (BiPAP) in the hospital. This enrollee may benefit from BiPAP with volume assurance during 
sleep as an outpatient. Medicare does not cover a home ventilator when used at settings that can be provided 
with BiPAP. The denial is upheld. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator system (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote monitoring of physiologic parameter(s) provided 
on June 16, 2023. 
 
You asked the Plan to pay for the remote monitoring of physiologic parameter(s). You say that the service 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 remote monitoring 
of physiologic parameter(s) provided on June 16, 2023.
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 needs this level of care. The 
Plan denied your request. The Plan says the enrollees medical condition does not require LTACH services, 
and care can be provided in another setting.  
 
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 the enrollee's care can be safely provided at the current facility until they are more 
stable and appropriate for transfer to another level of care. Completion of treatment at the current facility is 
recommended.  
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service August 29, 2023. 
 
You asked the Plan to pay for the billed testing. The Plan denied your request. The Plan says the testing has not 
been proven. 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. 
 
The file shows that a urinary tract infection panel test was provided. We looked at the file and Medicare rules. 
In this case, the documentation does not show that the testing was ordered due to insufficient results of 
traditional testing. The records do not show how the results of the panel test would impact treatment decisions 
for a specific medical problem. Based on this information, we decided that the Medicare rules for coverage 
have not been met. Therefore, we decided that the Plan does not have to pay for the panel testing billed for date 
of service August 29, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to reimburse you for miscellaneous durable medical equipment (E1399) provided 
April 6, 2023, to June 6, 2023. 
 
You asked the Plan to reimburse you for miscellaneous durable medical equipment. You say that you are on a 
fixed income, and you incurred a large amount of additional expenses during this ordeal. The Plan denied your 
request. The Plan says that the service on this claim is not covered by Medicare; therefore, it is not covered by 
your healthcare Plan.  
 
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 in this case specific information was required to substantiate the 
plans denial. The case file did not specify the items that were denied or show how the Plan determined the 
amount for the cost share. The required information was missing from the original file. A request for 
information was sent to the health plan on January 9, 2023, with a due date of January 12, 2023. As of the date 
of this letter, the plan has not responded to our request and/or submitted the required information Therefore, we 
decided that the Plan has to reimburse you for miscellaneous durable medical equipment (E1399) provided 
April 6, 2023, to June 6, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on July 20, 
2023, to August 09, 2023. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment for outpatient surgery/ambulatory surgical center. 
 
You have been asked to pay a $100 copayment for outpatient surgery. This item/service falls within the 
outpatient surgery/ambulatory surgical center 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 amount you owe is $200 ($100 x 2 visits = $200). Therefore, we 
decided that the Plan does not have to waive the copayment for outpatient surgery provided on July 20, 2023, 
to August 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on September 19, 2023. 
 
You asked the Plan to pay for the office visit (99214). You say that the service 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 office visit (99214) 
provided on September 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services received while on a cruise ship received on 
October 1, 2022. 
 
You asked the Plan to pay for the services received while on a cruise ship. You say that the travel insurance 
will not provider payment until they know if the Plan will provide payment. The Plan denied your request. The 
Plan says proof of payment was not provided. 
 
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 services received while on a cruise 
ship have been met. Review of the file shows that an itemized list of services and medical records were 
provided. However, the requested proof of payment was not received by the Plan. Without the proof of 
payment, the claim cannot be paid. Therefore, we decided that the Plan does not have to pay for the services 
received while on a cruise ship received on October 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha Sureclick. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the medication is not covered as a medical benefit 
under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha Sureclick.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99285) provided 
on February 27, 2023. 
 
You asked the Plan to pay for an emergency department visit (procedure 99285). You say that procedure code 
99285 is appropriate based on the services performed. The Plan denied your request. The Plan says the records 
do not support the services at issue in this case. 
 
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 an emergency department visit (procedure 99285). Our 
reviewer says that the service at issue in this case is not supported by the medical records. Our reviewer found 
that the documentation supports a medically appropriate history and examination but does not support high 
level decision-making. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (procedure 99285) have not been met. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit (procedure 99285) 
provided on February 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
September 20, 2023, and billed with codes 87481, 87651, 87798, 87640, and 87653. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel 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 urine polymerase chain reaction (PCR) panel provided on September 20, 
2023, and billed with codes 87481, 87651, 87798, 87640, and 87653.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the same-day outpatient surgery provided 
on March 28, 2023, to April 05, 2023. 
 
You asked the Plan to waive the copayment for the same-day outpatient surgery. You say that the cost share is 
wrong. 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 $325 
copayment for Outpatient hospital services. 
 
You have been asked to pay a $325 copayment for the same-day outpatient surgery. This item/service falls 
within the Outpatient hospital 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. Therefore, we decided that the Plan does not have to waive the copayment for 
the same-day outpatient surgery provided on March 28, 2023, to April 05, 2023.