Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the frames (V2020), the tint (V2744), the trifocal lenses (V2300), the 
ultraviolet lenses (V2755), the scratch-resistant coating (V2760), and the progressive lenses (V2781) on 
January 17, 2023. We decided that the Plan does not have to pay for the dilated macular or fundus exam 
(G8397) on January 17, 2023.  
 
You asked the Plan to pay for the frames (V2020), the tint (V2744), the dilated macular or fundus exam 
(G8397), the trifocal lenses (V2300), the ultraviolet lenses (V2755), the scratch-resistant coating (V2760), and 
the progressive lenses (V2781) provided on January 17, 2023. You say that you were told that your Plan 
exceeded all the services that are being denied. The Plan says that the benefits have been exhausted. 
 
We decided that the Plan has pay for the frames (V2020), the tint (V2744), the trifocal lenses (V2300), 
the ultraviolet lenses (V2755), the scratch-resistant coating (V2760), and the progressive lenses (V2781).  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers add-ons. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the Plan did not show which of the two vision benefit plans that 
you have chosen. This means we are unable to determine if the benefits have been exhausted for the frames 
(V2020).  
 
We looked at the file and the Plan's rules. Specifically, you would reasonably expect to pay $0 for the add-on 
services. Based on this information, we decided that the Plan's rules for coverage the tint (V2744), the trifocal 
lenses (V2300), the ultraviolet lenses (V2755), the scratch-resistant coating (V2760), and the progressive 
lenses (V2781) have been met. Therefore, we decided that the Plan has to pay for the frames (V2020), the tint 
(V2744), the trifocal lenses (V2300), the ultraviolet lenses (V2755), the scratch-resistant coating (V2760), and 
the progressive lenses (V2781) provided on January 17, 2023.  
 
We also decided that the Plan does not have to pay for the dilated macular or fundus exam (G8397). 
 
The record shows that the Plan has already paid for an eye exam. Therefore, we decided that the Plan does not 
have to pay for the dilated macular or fundus exam (G8397). 
 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the transport brackets, wheel lock, and trunk support 
hardware cover. 
 
You asked the Plan to pre-approve transport brackets, wheel lock, and trunk support hardware cover. You say 
that you want to appeal this denial. The Plan denied your request. The Plan says these items do not serve a 
medical purpose and therefore are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the transport brackets, wheel lock, and trunk support 
hardware cover.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided June 21, 2023, billed with 
codes 87651, 87640, 87481 x5, 87798 x13 and 87500. 
 
You asked the Plan to pay for the laboratory service. You say that please see the attached medical records for 
reconsideration of the Current Procedural Terminology (CPT) codes billed on your claim for services rendered. 
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. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory service provided June 21, 2023, billed with codes 87651, 87640, 
87481 x5, 87798 x13 and 87500.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81456) provided on June 27, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
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. Review of the claim does not show that the required unique identifier 
was reported. DEX Z-code ZB9GO is not listed as a valid Z-code for the billed code. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (81456) provided on June 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service coded as 87651-59, 87653-59, 87471-
59, 87481-59, 87551-59, 87798, 87500-59 and 87641-59 provided on December 5, 2022, by an out-of-network 
(OON) provider.  
 
You asked the Plan to pay for the laboratory services. You say that you are asking for reversal of the decision 
to deny these claims and reprocess your claims at in network costs and provide retro authorization that is 
required for further processing. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. Medicare rules also say that for tests for infectious agents, a 
single laboratory procedure shall be reported as one unit of service whether it generates one or multiple results. 
Multiple codes should only be used when multiple procedures, multiple methodologies, or multiple test kits are 
medically necessary and used to perform the test. 
 
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. Also, the documentation supports that this panel used the nucleic acid probe technique. 
There is no evidence that multiple procedures, multiple methodologies, or multiple kits were used in this case. 
As such, a single code with one unit of service should be used. 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 the laboratory 
service coded as 87651-59, 87653-59, 87471-59, 87481-59, 87551-59, 87798, 87500-59 and 87641-59 
provided on December 5, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs dispensed in the office for home use (D9630x2) 
provided from July 24, 2023, to July 27, 2023. 
 
You asked the Plan to pay for the drugs dispensed in the office for home use (D9630x2). You say that you were 
looking for an in-network dentist.  You say you were sent the wrong list of in-network providers. The Plan 
denied your request. The Plan says the Plan reprocessed the claim according to the in-network level of benefits 
to allow payment for covered services. However, the drugs dispensed in the office for home use (D9630x2) is 
not a covered a benefit. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the drugs dispensed in the office for 
home use (D9630x2) are not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pay for the drugs dispensed in the office for home use (D9630x2) provided from July 24, 2023, to 
July 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 26600 rendered on June 10, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 26600 - 54 (1 unit) remains not supported. 
 
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 26600 is ""Closed treatment of metacarpal fracture, 
single; without manipulation, each bone." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee was being treated for 
displaced fracture of base of fifth metacarpal bone of the right hand. She presented to the emergency 
department with right-hand pain. The right hand/wrist exam reveals swelling and tenderness. There is edema 
and tenderness of the lateral right wrist. She is able to move all fingers and make a fist. The x-rays confirmed a 
mildly displaced fracture through the base of the fifth metacarpal and an ulnar splint was applied. However, the documentation does not support any ongoing fracture care treatment was provided and the follow-up has not 
clearly occurred. Therefore, the documentation does not support that CPT 26600: closed treatment of 
metacarpal fracture, single; without manipulation, each bone was performed 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 26600 rendered on June 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain or ceramic pontic (D6245) for teeth 24, 25, 
and 26 and a porcelain or ceramic retainer crown (D6740) for tooth 27. 
 
You asked the Plan to pre-approve the dental services. You say that this is the only treatment option for the 
enrollee having any lower anterior teeth. 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 EOC 
says that the Plan covers one procedure code every five years. The record shows your benefit for the requested 
item or service was exhausted with this request or date of service. Therefore, we decided that the Plan does not 
have to pre-approve a porcelain or ceramic pontic (D6245) for teeth 24, 25, and 26 and a porcelain or ceramic 
retainer crown (D6740) for tooth 27.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are multiple in-network providers available. 
 
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 
an out-of-network referral.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service May 18, 
2023. 
 
You asked the Plan to pay for procedure code 99053. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says procedure code 99053 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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service May 18, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing services (G0482) provided on February 1, 2023. 
 
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says that the 
billed code is not supported. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the drug testing services by a contract provider. The file does not show that the Plan 
provided notice that the drug testing services would not be covered. Under Medicare rules, this means the drug 
testing services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the drug 
testing services (G0482) provided on February 1, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the inpatient hospital stay, the 
debridement procedures, and the clinic visit provided from April 21, 2023, to June 7, 2023. 
 
You asked the Plan to waive the copayments for the inpatient hospital stay, the debridement procedures, and 
the clinic visit. You say that you should not have to pay for the services that resulted from the infection 
acquired from the initial surgery. 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 $295 
copayment per day, for days one to seven of the inpatient hospital stay. Your contract with the Plan also clearly 
says that you must pay a $295 copayment for outpatient procedures at an outpatient hospital. Your contract 
with the Plan also clearly says that you must pay a $25 copayment for visits to a specialist. 
 
You have been asked to pay a $295 copayment per day, for days one to four of the inpatient hospital stay 
provided from April 21, 2023, to April 25, 2023. The amount you owe for the inpatient hospital stay is $1,180 
($295 copayment x 4 days = $1,180). This service falls within the inpatient hospital care benefit category. You 
have also been asked to pay a $295 copayment for each debridement procedure provided on May 3, 2023, May 
10, 2023, May 17, 2023, May 24, 2023, and May 31, 2023. These services fall within the outpatient surgery, 
including services provided at hospital outpatient facilities benefit category. You have also been asked to pay a 
$25 copayment for the clinic visit provided on June 7, 2023. This 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 copayments 
for the inpatient hospital stay, the debridement procedures, and the clinic visit provided from April 21, 2023, to 
June 7, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Nuvasive Attrax putty allograft. 
 
You asked the Plan to pre-approve Nuvasive Attrax putty allograft. You say that this is medically necessary for 
the enrollee. The Plan denied your request. The Plan says there is insufficient high-quality evidence to come to 
determine the efficacy and safety of these products on healthcare outcomes and how they compare with 
established bone grafting procedures. 
 
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 Nuvasive Attrax putty allograft. Our 
reviewer says that the requested Nuvasive Attrax putty allograft is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the requested allograft is experimental in spine 
surgery as additional research is needed. Therefore, the reviewer found that the requested 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 Nuvasive Attrax putty allograft have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Nuvasive Attrax putty allograft.
Appeal type: Other
Decision: Favorable

 
We decided that the Plan has to pre-approve revascularization (37228, 37229, 37230, 37231). 
 
You asked the Plan to pre-approve revascularization. You say that the services are necessary. The Plan denied 
your request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that PTA is covered when used under the certain 
conditions. 
 
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 revascularization. Our reviewer says 
that the services are medically necessary. Our physician reviewer found the documentation meets coverage 
criteria and supports the medical necessity of intervention.  The enrollee has documented claudication of the 
lower extremities and has documentation by two separate providers of distal lower extremity wounds. These 
wounds may suggest limb threatening ischemia. There is objective evidence of high-grade stenosis at both the 
iliac and femoral levels on a prior computed tomography angiography (CTA). The enrollee had been initially 
recommended a conservative approach, but his symptoms persist. At this point the plan for angiography and 
possible intervention meets coverage criteria and is reasonable and 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 revascularization have been met. Therefore, we decided that the Plan has to pre-
approve revascularization (37228, 37229, 37230, 37231).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultraviolet light therapy system (E0691) provided July 
26, 2023. 
 
You asked the Plan to pay for the ultraviolet light therapy system. You say that you have attached the 
supporting documentation. Please reprocess the claim. The Plan denied your request. The Plan says the service 
is not documented in the enrollee's medical records. 
 
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. The record does not show a diagnosis of psoriasis. There is also no 
indication that intractable psoriasis, as there is no indication the enrollee has failed other treatments for 
psoriasis. There are also no other factors described that would justify treatment at home rather than alternative 
sites, like a clinic or the hospital. Based on this information, we decided that Medicare rules for coverage of the 
ultraviolet light therapy system have not been met. Therefore, we decided that the Plan does not have to pay for 
the ultraviolet light therapy system (E0691) provided July 26, 2023.