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

 
We decided that the Plan does not have to pay for procedure codes 87481 and 87900 billed for date of service 
February 2, 2023. 
 
You asked the Plan to pay for procedure codes 87481 and 87900. You say that these services were necessary 
and are supported as billed. The Plan denied your request. The Plan says these services were not billed with an 
appropriate diagnosis code which supports the medical necessity of these services. 
 
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 pay for procedure codes 87481 and 87900. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the records provided in this case consist of the test requisition and the test 
results with no other supplied medical records documenting the need for CPT codes 87481 and 87900. 
Provided records do not document any medical notes indicating concern for a Candida infection or 
documentation as to why standard urine culture and susceptibility testing would not meet the enrollee's care 
needs.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87481 and 87900 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 87481 and 87900 billed for date of service February 2, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve one crown - porcelain fused to high noble metal 
(D2750). 
 
You asked the Plan to pre-approve one crown. You say that you need dentures to eat. 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 that three crowns (D2750) have been approved. The fourth crown exceeds your benefit. Therefore, we 
decided that the Plan does not have to pre-approve one crown - porcelain fused to high noble metal (D2750).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Orthofix-Trinity Elite allograft (20930).  
 
You asked the Plan to pre-approve the Orthofix-Trinity Elite allograft. You say that the enrollee is at 
immediate risk for prolonged pain and suffering.  The Plan denied your request. The Plan says the clinical 
value and effectiveness of Orthofix-Trinity Elite allograft in the setting of lumbar spine fusion surgery have not 
been demonstrated in the peer-reviewed literature.  
 
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 Orthofix-Trinity Elite allograft. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that there is limited published, large-scale, long-term peer-reviewed 
literature that shows this requested allograft to be an effective and/or safe treatment for the noted pathology. 
Further studies are needed to demonstrate this request has beneficial outcomes compared with conventional 
treatment. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested Orthofix-Trinity Elite allograft 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 the Orthofix-Trinity Elite allograft have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Orthofix-Trinity Elite allograft (20930).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93042 and 99053 billed for date of service 
March 21, 2022. 
 
You asked the Plan to pay for procedure codes 93042 and 99053. You say that these services are supported in 
the medical records. The Plan denied your request. The Plan says payment for code 93042 is bundled into 
payment for code 93010. Payment for code 99053 is always bundled to other services. 
 
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 93042 is a column II code to column I code 93010. This claim has 
not been billed with an appropriate modifier to bypass the edit. In addition, we find that procedure code 99053 
has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99053 is not 
separately payable. 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 codes 93042 and 99053 billed for date of service 
March 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty at T11, T12, and L2. 
 
You asked the Plan to pre-approve kyphoplasty. You say that the enrollee has tried conservative treatments 
without relief. The Plan denied your request. The Plan says the documentation notes retropulsion and canal 
stenosis on lumbar spine computed tomography (CT). 
 
The Plan follows Medicare rules. Medicare rules state that kyphoplasty is only covered if certain criteria 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 kyphoplasty. Our reviewer says that the 
enrollee does not meet criteria for the requested kyphoplasties. Our physician reviewer found the computed 
tomography (CT) scan of the lumbar spine corroborates minimal bony retropulsion at T11 and T12 fractures 
contribute to mild canal stenosis at T1 to T11 and T11 to T12. Not only is retropulsion demonstrated, there are 
also other probably causes of pain corroborated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty at T11, T12, and L2.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the care management services provided on March 03, 2023. 
 
You asked the Plan to pay for the care management services. You say that you were the only provider able to 
provide these services. 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 care management 
services provided on March 03, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on November 13, 2022, to 
December 12, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the home health services. You say that you are asking the Plan to please review 
and reprocess. The Plan denied your request. The Plan says the out-of-network services were not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for home health services provided on November 13, 
2022, to December 12, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 1, 
2023, through January 2, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was warranted 
and supported by clinical documentation. The Plan denied your request. The Plan says the enrollee could have 
stayed under observation care. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee presented to the emergency department with difficulty speaking and right 
facial droop. She reported no headache, or localized weakness. Examination confirmed the facial droop with 
normal extremity strength. It was noted that she had chronic gait abnormality, arthritis prior to this 
presentation. Computed tomography (CT)/CT angiography of the head was negative for acute abnormality, and 
labs were essentially unremarkable. Seizure was suspected by neurology and Keppra was started. Magnetic 
resonance imaging (MRI) showed left frontal cortex infarction. Speech improved within 24 hours of initial 
treatment. Vitals were stable, breathing status, and heart status were stable. As the patient was stable soon after 
workup was completed, and there was no evidence of organ damage or plans for an invasive procedure, with 
quick improvement in symptoms within 24 hours, it was not expected that the patient would require hospital 
care that would likely cross two midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from January 1, 2023, through January 
2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on October 21, 2022. 
 
You asked the Plan to pay for the office visit. You say that you were given incorrect insurance information by 
the enrollee. 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 provided 
on October 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on March 
14, 2023. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that the lab services should be 
included with the routine visit. 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 $10 
copayment for in-network outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $10 copayment for the laboratory services. This item/service falls within the in-network outpatient diagnostic tests and therapeutic services and supplies 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 laboratory services provided on March 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for end-stage renal disease (ESRD) provided on February 01, 
2023. 
 
You asked the Plan to pay for end-stage renal disease (ESRD). You say that this service is supported in the 
records. 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 end-stage renal disease 
(ESRD) provided on February 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital outpatient clinic visit provided on September 28, 
2022. 
 
You asked the Plan to pay for hospital outpatient clinic visit. 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 hospital outpatient clinic 
visit provided on September 28, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued home health services. 
 You asked the Plan to pre-approve home health services. You say that you need continued care because you are 
bedridden. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found there is no 
indication for continued skilled services. Your caregiver has been educated about your medical conditions and 
when to call a physician. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on 
December 11, 2022. 
 
You asked the Plan to waive the copayment for an 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 $350 
copayment for outpatient surgery/Medicare-covered surgery or other services provided to you at an ambulatory 
surgical. 
 
You have been asked to pay a $350 copayment for an outpatient surgery. This item/service falls within the outpatient surgery/Medicare-covered surgery or other services provided to you at an ambulatory surgical 
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, you are only being asked to pay $232.35 which is less than the required amount. Therefore, we 
decided that the Plan does not have to waive the copayment for an outpatient surgery provided on December 
11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L1 kyphoplasty. 
 
You asked the Plan to pre-approve kyphoplasty. You say that the enrollee is at risk of losing maximum 
function. The Plan denied your request. The Plan says there is no imaging documentation to support an 
acute/subacute fracture at L1. 
 
The Plan follows Medicare rules. Medicare rules state that kyphoplasty surgery is only covered if certain 
criteria 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 kyphoplasty. Our reviewer says that the 
enrollee does not meet criteria for the requested kyphoplasty. Our physician reviewer found imaging shows L1 
fracture retropulsion which is a contraindication to kyphoplasty. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L1 kyphoplasty.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 19, 2022, billed with 
codes 0031U, 0032U, 0033U, 81225, 81227, 81230, 81231, 81232, 81238, 81291, 81306, 81335, 81355 and 
81407. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 19, 2022, billed with codes 0031U, 0032U, 0033U, 81225, 81227, 81230, 81231, 81232, 81238, 81291, 
81306, 81335, 81355 and 81407.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthroplasty provided on August 08, 2022. 
 
You asked the Plan to pay for arthroplasty. You say that this service is supported in the records. 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 arthroplasty provided on 
August 08, 2022.