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

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on December 09, 
2022. 
 
You asked the Plan to pay for a hospital outpatient clinic visit. You say that the enrollee wishes to continue 
seeking services with this provider. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a hospital outpatient 
clinic visit provided on December 09, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided by a chiropractor on dates of service 
December 5, 2022, to December 15, 2022. 
 
You asked the Plan to pay for the billed services. You say that the cost of manipulative treatment should be 
covered. The Plan denied your request. The Plan says the billed services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The file shows that extraspinal manipulation (98943), traction (97012), and therapeutic exercise (97110) were 
provided. These services are not covered when provided by a chiropractor. Therefore, we decided that the Plan 
does not have to pay for the services provided by a chiropractor on dates of service December 5, 2022, to 
December 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluoroscopic guidance for needle placement (77002) 
provided on May 3, 2022. 
 
You asked the Plan to pay for the fluoroscopic guidance for needle placement (77002). You say that the 
attached medical records should be reviewed, and the claim processed as soon as possible. The Plan denied 
your request. The Plan says procedure code 77002 is an add-on code and that has been submitted without an 
appropriate primary procedure code. 
 
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 the 
77002 is an add-on code and has not been billed with an appropriate primary procedure code. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for the fluoroscopic guidance for needle placement (77002) provided on May 3, 2022.
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 is experimental when used as bone graft material in spine surgery. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator for 9 months (E0466). 
 
You asked the Plan to pre-approve a ventilator for 9 months. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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. 
 
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 ventilator for 9 months. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found provided records document 
that the home ventilator is being requested for use in targeted tidal volume - volume assured pressure support 
(TTV-VAPS) mode with auto-EPAP (AE) which could be provided by a bilevel positive airway pressure 
(BiPAP) device with average volume assured pressure support (AVAPS) and a back-up rate. Provided records 
do not document trial and failure of a BiPAP device with AVAPS and a back-up rate. 
 
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 ventilator for 9 months have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ventilator for 9 months (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on August 16, 
2022. 
 
You asked the Plan to pay for an office visit and related services. You say that the services should be covered. 
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 an office visit and 
related services provided on August 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on October 6, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says Medicare does not separately 
pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on October 
6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
December 13, 2022. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that this provider gave the 
incorrect boot type, and you do not feel you should have to pay this 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 $40 
copayment for in-network specialist physician/practitioner services. 
 
You have been asked to pay a $40 copayment for the specialist office visit. This item/service falls within the 
in-network specialist physician/practitioner 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 records show you are only being charged for the specialist 
office visit. Therefore, we decided that the Plan does not have to waive the copayment for the specialist office 
visit provided on December 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  a stance flexion feature (L5845), flex-walk system or 
equal (L5981), multi-axial rotation unit (L5986), and multiple ply prosthetic sock (L8430).  
 
You asked the Plan to pre-approve the items. You say that the items are medically necessary. The Plan denied 
your request. The Plan says the requested prosthesis/prosthetic parts exceed your need and cannot be approved. 
 
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 items. Our physician reviewer 
found the items are not medically necessary per LCD Lower Limb Prostheses L33787 and per Social Security 
Act, Section 1862 (a)1(A) and the 42 CFR Section 411.15(k), as Medicare does not pay for any items or 
services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve 
the functioning of a malformed body member. The Certified Prosthetist/Orthotist (CPO) states that you are a 
K3 ambulator, but this is not corroborated by the treating medical physician records as per Medicare 
guidelines. The prosthetist is the vendor. The physician documentation does not reveal your activities require 
the requested K3 foot. Furthermore, you use a cane and walker which is not consistent with a K3 level. The 
L5845 is not medically necessary as the approved knee unit comes with a knee flexion feature; therefore, this 
exceeds your functional need and is not medically 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 the items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve  a stance flexion feature (L5845), flex-walk system or equal (L5981), multi-axial rotation unit 
(L5986), and multiple ply prosthetic sock (L8430).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service December 
13, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity. We find that CPT code 99223 is 
not supported in the medical record. Specifically, the medical records do not include a comprehensive history 
or examination. 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 code 99223 billed 
for date of service December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on February 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 Plan's 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 February 22, 2023. 
Therefore, we decided that the Plan does not have to pay for the dental services on February 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87653, 87640, 87150, and 87641 billed for 
date of service October 5, 2022. 
 
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 the codes cannot be separately reimbursed. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   The file shows that the urinary tract infection diagnostic test provided, tests multiple pathogens. The medical 
records provided do not show that the services billed with the -59 modifier were distinct procedural services. 
Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87653, 87640, 
87150, and 87641 billed for date of service October 5, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 95822 billed for date of service March 8, 2022. 
 
You asked the Plan to pay for procedure code 95822. You say that these services were reported appropriately. 
The Plan denied your request. The Plan says that this code is not supported by the medical records provided. 
The services provided would be better reported with code 95955. 
 
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 95822 is electroencephalogram (EEG); recording in coma or sleep only. 
 
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 code 95822. Our reviewer says that the criteria for 
this code are met in this case. Our reviewer found that the procedure report describes neuromonitoring service 
provided for anterior cervical discectomy and fusion (ACDF) C3-C7 surgical procedure. In this case, the code 
recommended by the Plan, EEG recording during non-intracranial surgery (e.g., carotid surgery) (95955), is an 
inappropriate code to report as this procedure would be reported when the provider uses 
electroencephalographic monitoring of a patient during non-intracranial surgery like cardiac surgery or carotid 
stenting. Therefore, CPT 95822 would be reported in this case. 
 
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 code 95822 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 95822 billed for date of service March 8, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for each radiation therapy service provided on 
October 26, 2022, to December 27, 2022. 
 
You asked the Plan to reduce the copayment for each radiation therapy service. You say that there should only 
be a $35 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 $75 
copayment for outpatient hospital services. 
 
You have been asked to pay a $75 copayment for each radiation therapy service. 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 reduce the copayment for 
each radiation therapy service provided on October 26, 2022, to December 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 94761 and 99072 billed for date of service 
December 13, 2022. 
 
You asked the Plan to pay for procedure codes 94761 and 99072. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says procedure code 99072 is considered bundled and not 
separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable. Code 94761 has a status indicator of T on the Physician Fee 
Schedule. This means this code is only paid if there are no other services payable under the physician fee 
schedule billed on the same date by the same provider. Other services were paid under the physician fee 
schedule billed on the same date by the same provider. This means code 94761 is not payable as billed. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 94761 and 99072 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 94761 and 
99072 billed for date of service December 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each urgent care visit provided on October 
30, 2022, to November 19, 2022. 
 
You asked the Plan to waive the copayment for each urgent care visit. You say that your specialist office visit 
copayment is only $30. 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 $40 
copayment for urgently needed services. 
 
You have been asked to pay a $40 copayment for each urgent care visit. This item/service falls within the 
urgently needed 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 you owe is $80 ($40 copayment per visit x 2 visits = $80). Therefore, we decided 
that the Plan does not have to waive the copayment for each urgent care visit provided on October 30, 2022, to 
November 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on December 28, 2022. 
 
You asked the Plan to pay for office visit. You say that you say that you changed from your previous provider 
then ended up with another. 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 office visit provided on 
December 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97810, 97811) and the infrared 
therapy (97026) provided on August 25, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not payable as they were 
rendered by an ineligible provider.  
 
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. 
 
A review of the file and Medicare records indicates that you are not enrolled in the Medicare program.  
  
 
Therefore, we decided that the Plan does not have to pay for the acupuncture treatments (97810, 97811) and the 
infrared therapy (97026) provided on August 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy provided on March 02, 
2023. 
 
You asked the Plan to waive the coinsurance for chemotherapy. You say that you were not aware the cost 
would be so high for the injection. 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 Medicare Part B Prescription Drugs. 
 
You have been asked to pay 20% coinsurance for chemotherapy. This item/service falls within the Medicare 
Part B Prescription Drugs 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 you owe is $520.39, which is 20% of the allowed amount for Medicare Part B 
chemotherapy drugs ($2,601.96 allowed x 20% = $520.39). Therefore, we decided that the Plan does not have 
to waive the coinsurance for chemotherapy provided on March 02, 2023.