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

 
We decided that the Plan does not have to pay for the genetic testing provided on June 19, 2023, billed with 
codes 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81334 and 81351. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was 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 
June 19, 2023, billed with codes 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81334 and 81351.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the mattress and adjustable base (A9270, A9901) 
and sales tax (S9999) purchased August 22, 2023. 
 
You asked the Plan to reimburse you for the mattress and adjustable base. You say that the mattress and base 
were recommended by your doctor and has helped tremendously to alleviate back pain. The Plan denied your 
request. The Plan says the item was purchased from a supplier that does not participate with Medicare. 
 
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. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for the mattress and adjustable 
base (A9270, A9901) and sales tax (S9999) purchased August 22, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 73562 and 73552 provided on August 13, 
2023. 
 
You asked the Plan to pay for procedure codes 73562 and 73552. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the billed codes are 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 CPT code. 
 
We find that CPT codes 73562 and 73552 are not supported in the medical record. Specifically, these codes are 
assigned a Q1 indicator and were billed the same date of service as code 99284 which has a status indicator of 
"V". These codes are considered packaged and not separately payable. Based on this information, we decided 
that Medicare rules for coverage of procedure codes 73562 and 73552 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 73562 and 73552 provided on August 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a hand splint provided on July 19, 2023. 
 
You asked the Plan to waive the deductible for a splint. You say that you looked at the same item on the shelf 
and they were a fraction of this price. 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. Your 
contract with the Plan says that there is a $500 deductible which applies to durable medical equipment (DME) 
and related supplies. You have been asked to pay $91.27 towards this deductible. 
 
The item or service you asked the Plan to waive the deductible for falls within the durable medical equipment 
(DME) and related supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $500 deductible which applies to durable medical equipment (DME) and related 
supplies. This cost sharing is a contractual obligation that had not been met at the time a splint was received on 
July 19, 2023. Therefore, we decided that the Plan does not have to waive the deductible for a hand splint 
provided on July 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) provided on 
January 20, 2023. 
 
You asked the Plan to pay for the PCD. The Plan denied your request. The Plan says the documentation 
requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the pneumatic compression device (PCD) provided on January 
20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve VIA Disc NP. 
 
You asked the Plan to pre-approve VIA Disc NP. You say that the VIA Disc NP is medically necessary. The 
Plan denied your request. The Plan says the VIA Disc NP is unproven and not medically necessary. 
 
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 VIA Disc NP. Our reviewer says that 
the requested VIA Disc NP is not considered medically reasonable and necessary. Our physician reviewer 
found that this is considered experimental therapy. Therefore, the request is deemed not medically reasonable 
and 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 VIA Disc NP have not been met. Therefore, we decided that the Plan does not 
have to pre-approve VIA Disc NP.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network laboratory service 
provided on August 17, 2023, to August 22, 2023. 
 
You asked the Plan to waive the coinsurance for an out-of-network laboratory service. You say that you were 
not aware of the lab going out-of-network. 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 47% 
coinsurance for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay 47% coinsurance for an out-of-network laboratory service. This item/service falls 
within the 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. The total you owe is $31.10 
($24.91+$6.19= $31.10). Therefore, we decided that the Plan does not have to waive the coinsurance for an 
out-of-network laboratory service provided on August 17, 2023, to August 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT capture (D0381) provided on July 6, 2023. 
 
You asked the Plan to pay for D0381. You say that you need this due to the stroke you had. The Plan denied 
your request. The Plan says the denied dental service is not a covered 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 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 cone 
beam CT capture (D0381) provided on July 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the panoramic radiographic image (D0330) and reline 
maxillary partial denture (indirect) (D5760) provided on March 9, 2023, and March 13, 2023. We also decided 
that the Plan does not have to pay for the interim partial denture (including retentive/clasping materials, rests, 
and teeth) (D5821) provided on March 9, 2023. 
 
 You asked the Plan to pay more for the panoramic radiographic image and reline maxillary partial denture. You 
also asked the Plan to pay for the interim partial denture. You say that you were told by the plan representative 
the services would be covered and were provided on a predetermination. The Plan denied your request. The 
Plan says you are responsible for any charged amount above the Plans cost-sharing amount when your 
services are received from an out-of-network provider. The Plan also says the interim partial denture is not a 
covered expense under your dental plan. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the panoramic radiographic image (D0330) 
and reline maxillary partial denture (indirect) (D5760) provided on March 9, 2023, and March 13, 2023.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the interim partial denture is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
interim partial denture (including retentive/clasping materials, rests, and teeth), mandibular (D5821) provided 
on March 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88374 and 88377 provided on July 13, 
2023. 
 You asked the Plan to pay for procedure codes 88374 and 88377. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say providers/suppliers shall not report more than one 
unit of service for CPT codes 88366, 88374, or 88377 per specimen for each multiplex probe staining 
procedure even if it contains multiple separately interpretable probes. 
 
In this case, procedure codes 88374 and 88377 should be billed per specimen, rather than per test. Based on 
this information, we decided that Medicare rules for coverage of procedure codes 88374 and 88377 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 88374 and 88377 
provided on July 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rolling walker (E0143, E0156). 
 
You asked the Plan to pre-approve the rolling walker. You say that this item is medically necessary. The Plan 
denied your request. The Plan says coverage rules are not met. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has a walker. The walker serves the same purpose as the requested rolling 
walker. Therefore, we decided that the Plan does not have to pre-approve a rolling walker (E0143, E0156).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for swimming membership provided on January 1, 2023. 
 
You asked the Plan to reimburse for swimming membership. You say that you do not understand why this is 
not covered under your member benefits for health clubs. The Plan denied your request. The Plan says this is 
not a covered benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only when the reimbursement request is from a qualified health club or fitness facility. 
 
 
  The Plans rules for coverage of gym benefits have not been met because swimming memberships are not a 
qualified health club or fitness facility. Therefore, we decided that the Plan does not have to reimburse for 
swimming membership provided on January 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on June 6, 2023, billed with 
procedure codes 92004 and 92250-59. 
 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 the diagnosis code at issue is not appropriate as a 
primary diagnosis. 
 
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code E08.3293, 
described as diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy 
without macular edema, bilateral. This code is not an appropriate primary diagnosis as the code has a code first 
note indicating to code the underlying condition first. Based on this information, we decided that Medicare 
rules for payment of this claim have not been met. Therefore, we decided that the Plan does not have to pay for 
practitioner services provided on June 6, 2023, billed with procedure codes 92004 and 92250-59.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compressor (E0650), segmental gradient 
pressure pneumatic appliances (E0673 x2), and orthotic(s) management and training (97760) provided on 
February 28, 2023. 
 
  You asked the Plan to pay for the pneumatic compressor, segmental gradient pressure pneumatic appliances, 
and orthotic(s) management and training. You say that you would like the records to be reviewed and the claim 
to be processed accordingly. The Plan denied your request. The Plan says this request is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a PCD that provides intermittent limb 
compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. 
Medicare rules also say that items that are used for a preventative service or function are excluded from 
coverage under the Medicare DME benefit. 
 
We looked at the file and Medicare rules. Specifically, this PCD that is meant to prevent deep vein thrombosis 
is a considered a preventive device and is not covered. These devices should be billed with code E0676. Based 
on this information, we decided that Medicare rules for coverage of the pneumatic compressor, segmental 
gradient pressure pneumatic appliances, and orthotic(s) management and training have not been met. 
Therefore, we decided that the Plan does not have to pay for the pneumatic compressor (E0650), segmental 
gradient pressure pneumatic appliances (E0673 x2), and orthotic(s) management and training (97760) provided 
on February 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for tennis club membership provided on January 1, 2023. 
 
You asked the Plan to reimburse for tennis club membership. You say that all this year you have been 
reimbursed. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only when the request for reimbursement is a qualified health club or fitness facility. 
 
 
  The Plans rules for coverage of gym benefits have not been met because the request is not a qualified health 
club or fitness facility. The record shows that tennis club memberships are excluded from this benefit. 
Therefore, we decided that the Plan does not have to reimburse for tennis club membership provided on 
January 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the retainer crowns - porcelain/ceramic (D6740 x2) 
provided on August 10, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the services are covered and your benefit 
maximum has not been exceeded. You also say that the small portion being denied should be paid based upon 
stated benefits. The Plan denied your request. The Plan says your benefit for the requested item or service 
$1,7500 dollar limit was met 
 
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, certain limitations apply. The record 
shows your benefit for dental services has been exhausted. The Plan has provided evidence of having made 
payments totaling $1,750 towards the cost of dental services provided in 2023. This included payments of 
$40.88, $13.26, $561.00 and $172.42 which was applied to your maximum benefit for services provided on 
date of service August 10, 2023. Therefore, we decided that the Plan does not have to pay more for the retainer 
crowns - porcelain/ceramic (D6740 x2) provided on August 10, 2023.  
 
Your complaint about belonging to a company that does not live up to their promises is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sleep study (95800) provided on November 28, 2022, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the sleep study. You say that you are attaching the medical records and other 
supporting documents to prove that this was a necessary service. 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. 
 
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 the sleep study (95800) provided on November 28, 
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 inpatient hospital services provided on March 9, 2023, to 
March 13, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was accurately billed with the appropriate DRG. The Plan denied your request. The Plan says the medical 
records did not have sufficient documentation to clinically validate the diagnosis of I21.A1 (myocardial 
infarction type 2). 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with I21.A1, defined as myocardial infarction type 2. 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 the inpatient hospital services at the DRG 
originally billed. Our physician reviewer found that the medical records did not show evidence that the enrollee 
had a myocardial infarction. Therefore, the billing of I21.A1 is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on March 9, 2023, to March 13, 2023, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the seat lift mechanism (E0629, S9999) provided on July 11, 
2023.provided on July 11, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the seat lift mechanism. The Plan denied your request. The Plan says the item in 
question 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 item at issue in this appeal. The Plan did not pre-approve the item at 
issue. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for the seat lift mechanism (E0629, S9999) provided on July 11, 2023.provided on 
July 11, 2023, by an out-of-network (OON) provider.