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

 
We decided that the Plan does not have to waive the cost share for the injections and an office visit on July 28, 
2023. 
 
You asked the Plan to waive the cost share for the injections and an office visit. You say that you received the 
first injection on 01/20/23 and your responsibility was $40. 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% 
coinsurance for all other Medicare-covered Part B drugs. You must pay a $40 copayment for services from a 
specialist or under certain circumstances, treatment by a nurse practitioner, physicians assistant or other non-
physician health care professional in a specialists office (as allowed under Medicare). The overall cost share is 
calculated by taking the Medicare allowed amount and subtracting the plan paid amount and the sequestration 
amount. In this case, $1487.92 Medicare allowed - $1164.04 plan paid - $0.36 sequestration = $323.52. 
Therefore, results in the total cost sharing of $323.52. 
 
You have been asked to pay a $323.52 cost share for the injections and an office visit. This item/service falls 
within the Medicare Part B prescription drugs and 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 cost share for the injections and an office visit 
on July 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lenses (V2788) provided on August 11, 2023 to August 25, 
2023. 
 
You asked the Plan to pay for the lenses. You say that the lenses should be covered. The Plan denied your 
request. The Plan says the correct cost-sharing was applied. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for lenses (V2788) 
provided on August 11, 2023 to August 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) and the massage therapy (97124) 
provided on September 1, 2023. 
 
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 the services are not covered by Medicare or 
the Plan.  
 
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 records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit (99203) and the massage therapy (97124) provided on 
September 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87491 and 87640 billed for date of service 
August 24, 2023. 
 
You asked the Plan to pay for the billed testing. You say that the codes are approved by Medicare. The Plan 
denied your request. The Plan says the billed codes are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the CPT Code Manual definition of code 87491 is infectious agent detection by nucleic acid (DNA 
or RNA); Chlamydia trachomatis, amplified probe technique. We find that CPT code 87491 is not supported. 
The medical records do not show that this test was a part of the panel provided, or that the testing was 
provided.  
 
We find that CPT code 87640 is a column II code to column I code 87641. Code 87640 was billed with the -59 
modifier. The records do not show that code 87640 was a separate and distinct procedure. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure codes 87491 and 87640 billed for date of service August 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on July 7, 2023. billed with 
procedure code 97608-AS. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed 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, the CPT Code Manual definition of code 97608 is negative pressure wound therapy, (eg, vacuum 
assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing 
care, per session; total wound(s) surface area greater than 50 square centimeters. 
 
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 the practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the procedure report does not include 
sufficient documentation to support the procedure code billed for negative pressure wound therapy. Codes 
97605 and 97606 are used for placement of a non-disposable wound vac device, while codes 97607 and 97608 
are used if the wound vac is disposable. The codes are further differentiated by the wound size, either greater 
than 50 sq cm, or less than or equal to 50 sq cm. In this case, the more specific code cannot be verified in the 
documentation submitted. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on July 7, 2023. billed with procedure code 
97608-AS.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99001 billed for date of service July 31, 
2022. 
 
You asked the Plan to pay for procedure code 99001. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says procedure code 99001 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 99001 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99001 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99001 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99001 billed for date of service July 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service July 5, 2023. 
 
You asked the Plan to pay for procedure code 99100. You say that 99100 should be paid as billed because it is 
supported in the documentation. The Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service July 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluid circulating cold pad with pump, any type (E0218) 
provided May 16, 2023, to June 9, 2023. 
 
You asked the Plan to pay for the fluid circulating cold pad with pump. You say that you are requesting 
reconsideration based on medical necessity for this enrollee and evidence based medical literature that 
substantiate the efficacy of the treatment rendered. The Plan denied your request. The Plan says this service is 
not covered by Medicare or the Plan. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the fluid circulating cold pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for the fluid circulating cold pad with pump, any type (E0218) provided May 16, 2023, to 
June 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the gingivectomy (D4212) for tooth #30. 
 
You asked the Plan to pre-approve the dental service. You say that you are in severe pain and your doctor has 
indicated the dental services are medically necessary. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because the gingivectomy is not covered by the Plan. 

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, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
gingivectomy (D4212) for tooth #30.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight (8) fractions of image-guided, intensity-modulated 
radiation therapy (IG-IMRT) (77014, G6015). 
 
You asked the Plan to pre-approve IG-IMRT. You say that you disagree with the denial. The Plan denied your 
request. The Plan says prostate radiation is not considered necessary past 20 treatments. 
 
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 IG-IMRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is being offered 28-fraction of IMRT in the setting of a bone and lymph node 
metastases and would qualify as "low metastatic burden", and therefore the potential benefit of prostate/pelvic 
radiotherapy is supported by published evidence and guidelines. Nevertheless, pelvic/prostate radiotherapy is 
not under dispute, nor IMRT but rather the delivery of 28 versus 20 fractions of IMRT. The delivery of more 
than 20 fractions of radiation in the metastatic setting seems outside of the standard of care based on National 
Comprehensive Cancer Network (NCCN) guidelines. The case file does not document the need for going 
outside of the standard of care. The decision is unfavorable for the additional 8 fractions of IMRT as it would 
not be delivered according to accepted standards of medical practice, nor is it supported in the case records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IG-IMRT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve eight (8) fractions of image-guided, intensity-modulated radiation therapy (IG-IMRT) (77014, 
G6015).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88172, 88173 and 88177 billed for date of 
service April 28, 2023. 
 
You asked the Plan to pay for procedure code 88172, 88173 and 88177. You say that the medical records 
provided support the necessity of the billed services in dispute. The Plan denied your request. The Plan says 
payment for code 88172 and 88173 is bundled into payment for code 88104. The number of units billed 
exceeds the maximum allowed for code 88177. 
 
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 88172 
and 88173 is a column II code to column I code 88104. This claim has not been billed with an appropriate 
modifier to bypass the edit. Also, the MUE for CPT code 88177 is 6. The MAI value for this code is 3. You 
billed 7 units of this code, exceeding the MUE. You did not provide all the required evidence showing that the 
excess units were actually provided, were correctly coded, and were medically necessary. 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 88172, 88173 and 88177 billed for date of service April 28, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says all of the criteria are not met.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for surgical repair of a radius fracture on 12/12/23 and has beem discharged home. Medical problems 
are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this patient will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic care provided on August 22, 2023. 
 
You asked the Plan to pay for the chiropractic care. You say that you are appealing the claim payment denial. 
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 chiropractic care 
provided on August 22, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mobile cardiac outpatient telemetry (MCOT) monitor 
(93228). 
 
You asked the Plan to pre-approve a MCOT monitor. 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 follows Medicare rules. Medicare rules say that CED) is covered under certain circumstances. 
 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 MCOT monitor. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the enrollee had documented atrial 
fibrillation at a recent office visit. It is not clear how MCOT monitoring would help to further characterize their 
symptoms. In summary, there is insufficient documentation to support the medical necessity for an MCOT 
monitor in this enrollee's clinical management. 
 
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 MCOT monitor have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a mobile cardiac outpatient telemetry (MCOT) monitor (93228).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Skyrizi pen. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary. 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 a Skyrizi pen.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #26. 
 
You asked the Plan to pre-approve the dental service. You say that the services are medically necessary 
because you have sensitivity, and you cannot 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 your benefit for the requested item or service was exhausted on date of service November 21, 2023. 
Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth #26.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87798, 87640, 87651, and 87641 billed for 
date of service August 28, 2023. 
 
You asked the Plan to pay for the billed codes. You say that medical records were provided. The Plan denied 
your request. The Plan says the codes are bundled into payment for code 87801. 
 
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 codes 87798, 87640, 87651, and 87641 are column II codes to column I 
code 87801. The codes at issue were billed with the -59 modifier. The testing was part of panel testing 
provided. The records submitted do not show that the individual codes were separate and distinct services. 
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 procedure codes 87798, 87640, 87651, and 87641 billed for date 
of service August 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone graft (D6104), the collection and application of 
autologous blood concentrate product (D7921) and a therapeutic parenteral drug, single administration (D9610) 
provided on July 6, 2023. 

You asked the Plan to pay for a bone graft (D6104), the collection and application of autologous blood 
concentrate product (D7921) and a therapeutic parenteral drug, single administration (D9610). You say that 
you had to have an implant because there was a missing/broken tooth. The Plan denied your request. The Plan 
says the services are not covered. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a bone 
graft (D6104), the collection and application of autologous blood concentrate product (D7921) and a 
therapeutic parenteral drug, single administration (D9610) provided on July 6, 2023.