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

 
We decided that the Plan does not have to pay for procedure code 96127 billed for date of service June 1, 2023. 
 
You asked the Plan to pay for procedure code 96127. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 96127 is bundled into payment for code G0438. 
 
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 96127 
is a column II code to column I code G0438. 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 96127 billed for date of service June 1, 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 a dermatologist is needed for continuity of 
care. The Plan denied your request. The Plan says the Plan does not cover out-of-network services 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate remains experimental. More research is needed.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate (20939).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barostim NEO IPG. 
 
You asked the Plan to pre-approve the IPG. You say that the enrollee's heart failure is progressively worsening 
requiring the need for this procedure. The Plan denied your request. The Plan says this procedure is not 
supported by research and is not covered. 
 
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 IPG. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the Barostim NEO IPG is considered experimental/investigational and is not medically 
necessary for the treatment of chronic systolic heart failure. 
 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 IPG have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Barostim NEO IPG.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a pulmonary visit provided on July 31, 
2023. 
 
You asked the Plan to waive the copayment for a pulmonary visit. You say that you feel you do not owe this 
copayment as you had already paid for the test. 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 physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $20 copayment for a pulmonary visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 a pulmonary visit provided on July 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive medicine services, the provider services, and 
the laboratory services provided on June 27, 2023. 
 
You asked the Plan to pay for the preventive medicine services, the provider services, and the laboratory 
services. You say that you are requesting reconsideration of the denied claim. 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 preventive medicine 
services, the provider services, and the laboratory services provided on June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on May 25, 
2023, to June 01, 2023. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that you are requesting 
reconsideration of the denied claim. 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 subsequent nursing 
facility care provided on May 25, 2023, to June 01, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from June 5, 2023, to June 11, 
2023. 
 
You asked the Plan to pay for the home health services. You say that you billed this claim correctly. The Plan 
denied your request. The Plan says this claim was billed with an incorrect Type of Bill code. 
 
The Plan must follow Medicare rules. Medicare rules say that the Type of Bill code is a 4-digit alphanumeric 
code that gives two pieces of information. The first three digits indicate the base type of bill. The fourth digit 
indicates the sequence of this bill in this particular period of care. The acceptable 4th digit options are as 
follows: 7 (to indicate a replacement of a prior claim); 8 (to indicate a void or cancel of a prior claim); and 9 (a 
final claim). 
 Based on this rule, you should have billed this claim with either code 0329 or 0327. Instead, you billed with 
code 0323, which is not correct. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to 
pay for home health services provided from June 5, 2023, to June 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64493 and 64494 billed for date of service 
July 24, 2023. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says an appropriate diagnosis code was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT codes 64493 and 64494 were billed with diagnosis code M54.16, defined as lumbar 
radiculopathy. We find that this diagnosis is not among those covered for the services provided. Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 64493 and 64494 billed for date of service 
July 24, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac calcium score test. 
 
You asked the Plan to pre-approve cardiac calcium score test. You say that you believe that your symptom of 
getting tired easily may be associated with a heart problem. You say that a simple walk form one room to 
another in your home sometimes leads to exhaustion.  The Plan denied your request. The Plan says cardiac 
calcium score test is not medically necessary and does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a cardiac calcium score test is covered when the 
criteria listed in the Medicare rules section of this decision are met. 
 
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 cardiac calcium score test. Our 
reviewer says that the requested cardiac calcium score test is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that numerous studies have demonstrated that coronary 
artery calcium (CAC) scoring using ultrafast cardiac CT adds predictive value in assessing risk of coronary 
heart disease (CHD). Clinical studies have not, however, shown that CAC scoring adds value in clinical 
management of asymptomatic patients in whom risk factors are targeted. Mamadu in 2014 examined whether CAC scoring in asymptomatic adults might have an effect on behavior modification, risk perception, and 
medication adherence. While CAC screening improved medication adherence, the impact of CAC scoring on 
behavioral and lifestyle factors, perception of CHD risk, and psychosocial effects was not statistically 
significant compared with baseline. In summary, current evidence showing that the use of CAC scores in 
clinical management of asymptomatic individuals leads to changes in patient management or in individual risk 
behaviors that improve cardiac outputs outcomes is limited and inconclusive.  Overall, there is insufficient 
support in the peer-reviewed literature demonstrating a significant benefit of CT imaging of the heart with 
quantitative evaluation of coronary calcium in guiding optimal management of this patient. As such, CT 
imaging of the heart without contrast material with quantitative evaluation of coronary calcium is considered 
experimental/investigational for the evaluation and management of your medical condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiac calcium score test have not been met. Therefore, we decided that the 
Plan does not have to pre-approve cardiac calcium score test.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the periodontal scaling and root plaing (D4341) for the upper left 
quadrant. 
 
You asked the Plan to pre-approve the dental service. You say that the enrollee has heavy sub and supra 
tenacious and over 2mm bone loss. The Plan denied your request. The Plan says that the denial of authorization 
for this service is correct, because the enrollee does not have 4 teeth affected in the quadrant. 
 
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 Plan covers the dental 
service when the services are medically necessary and reasonable. 
 
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 dental service. Our reviewer says 
that the periodontal scaling and root plaing (D4341) for the upper left quadrant criteria of coverage has been 
met. Our physician reviewer found that the review of the documentation indicates that scaling and root planing 
has been approved in 3 quadrants. The maxillary left quadrant reveals subgingival calculus and bone loss. The 
criteria for coverage have been met in this quadrant also to treat the enrollee's periodontal disease. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental service have been met. Therefore, we decided that the Plan has to 
pre-approve the periodontal scaling and root plaing (D4341) for the upper left quadrant.  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
provider.  
 
You asked the Plan to pre-approve an office visit to be provided by an out-of-network provider. You say that 
you are requesting to speak to an individual therapist, one who you can connect with on a deeper level and be 
able to have ongoing therapy to help your mental state of mind. The Plan denied your request. The Plan says 
members will obtain services from out-of-network providers if the services are emergent/urgent or not 
available within the members network. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office 
visit to be provided by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dual-energy X-ray absorptiometry (DXA) (77085) 
provided on August 1, 2023. 
 
You asked the Plan to pay for the DXA. You say that the service was billed correctly and should be paid. The 
Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that R29.890 has an Excludes1 note in relation to M81.0. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the DXA have not been met. Therefore, we decided that the Plan does not have to pay for the 
dual-energy X-ray absorptiometry (DXA) (77085) provided on August 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80053 and 85025 billed for date of service 
March 29, 2023. 
 
You asked the Plan to pay for procedure codes 80053 and 85025. You say that the services at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the provided 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 code 80053 is: Comprehensive metabolic panel This panel 
must include the following: Albumin (82040) Bilirubin, total (82247) Calcium, total (82310) Carbon dioxide 
(bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Phosphatase, alkaline (84075) 
Potassium (84132) Protein, total (84155) Sodium (84295) Transferase, alanine amino (ALT) (SGPT) (84460) 
Transferase, aspartate amino (AST) (SGOT) (84450) Urea nitrogen (BUN) (84520). 
 
The definition of code 85025 is: Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet 
count) and automated differential WBC count. 
 
We find that CPT codes 80053 and 85025 are not supported in the medical record. Specifically, a physician 
order and requisition for the services at issue has not been provided for review. Therefore, the codes at issue 
cannot be verified. Based on this information, we decided that Medicare rules for coverage of procedure codes 
80053 and 85025 have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes 80053 and 85025 billed for date of service March 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Vitamin D testing (82306) provided on July 21, 2023. 
 
You asked the Plan to pay for Vitamin D testing. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules list the ICD-10-CM codes support the medical necessity 
of CPT code 82306. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Vitamin D testing have not been met. Specifically, the diagnosis codes reported on the claim at 
issue are not listed in the rules as supporting medical necessity for procedure code 82306.  
  Therefore, we decided that the Plan does not have to pay for Vitamin D testing (82306) provided on July 21, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service September 16, 2023. 
 
You asked the Plan to pay for the billed testing. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says an appropriate code was not billed. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. We looked at the file and Medicare rules. The provided Guardant Reveal test has not met the Medicare 
reasonable and necessary requirements. Based on this information, we decided that Medicare rules for coverage 
of the billed testing have not been met. Therefore, we decided that the Plan does not have to pay for the lab 
testing billed for date of service September 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee replacement. 
 
You asked the Plan to pre-approve a knee replacement. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 a knee replacement. 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 compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested partial medial right knee 
arthroplasty using MAKOplasty (27446) is not medically reasonable or necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a knee replacement have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a knee replacement.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an abdomen x-ray provided on August 28, 
2023. 
 
You asked the Plan to waive the copayment for an abdomen x-ray. You say that an annual kidney x-ray is 
medically necessary. 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 $35 
copayment for each in-network Medicare-covered standard x-ray service. 
 
You have been asked to pay a $35 copayment for an abdomen x-ray. This item/service falls within the each in-
network Medicare-covered standard x-ray service benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, since the allowed amount is less than the standard 
copayment, you only owe $22.88. Therefore, we decided that the Plan does not have to waive the copayment 
for an abdomen x-ray provided on August 28, 2023.