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

 
We decided that the Plan does not have to pre-approve Kerecis Omega3 Wound. 
 
You asked the Plan to pre-approve Kerecis Omega3 Wound. You say that the Kerecis Omega3 Wound is 
medically necessary. The Plan denied your request. The Plan says the Kerecis Omega3 Wound is 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 Kerecis Omega3 Wound. Our reviewer 
says that the requested Kerecis Omega3 Wound is not considered medically reasonable and necessary. Our 
physician reviewer found the medical documentation supports that this enrollee has undergone a partial fifth 
ray amputation left side. The surgery was performed on September 28, 2023. As of November 16, 2023, the 
wound measured 5 x 8.5 x 0.2 cm. The medical documentation supports that on December 14, 2023, the wound measured 1.2 cm. Medicare guidelines advise that they will pay for items or services that are reasonable and 
necessary for the diagnosis or treatment of an illness or injury. These treatments must be safe and effective, not 
mainly for the convenience of the patient or the physician, not experimental or investigational, appropriate in 
that they are furnished in accordance with accepted standards of medical practice for the diagnosis or treatment 
of the patients condition, one that meets but does not exceed the patients medical needs, and at least as 
beneficial as existing and available medically appropriate alternatives. In this particular case the wound does 
not appear to be a non-healing wound. Between the dates of November 16, 2023, and December 14, 2023 the 
wound is noted to have reduced in size. The wound appears to be responding well to conservative treatments 
including wound dressings, wound debridement, and wound VAC. Therefore, the recommended Kerecis 
omega-3 wound skin substitute 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 Kerecis Omega3 Wound have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Kerecis Omega3 Wound.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA genetic testing. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that BRCA genetic testing is covered when specific 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee's biopsy showed invasive 
ductal carcinoma with mucinous features, grade two, estrogen receptor (ER) 100 percent, progesterone receptor 
(PR) 95 percent and HER2 negative. She has two maternal cousins with breast cancer. The requested panel has 
genes that are not relevant to the enrollee's personal and family history. The records do not support that the 
criteria for coverage are met; therefore, the BRCA testing is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve BRCA genetic testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services described by codes 96372, J0223, and 
J0223-JW billed for date of service February 2, 2022.  
 
You asked the Plan to pay for the injection services. You say that the injection services should be paid as billed 
because they were medically necessary and are supported in the medical record. The Plan denied your request. 
The Plan says the injection services are denied because they were billed on a claim with frequency code 8. 
 
The Plan must follow Medicare rules. Medicare rules say that frequency code 8 on the claim form indicates the 
voiding or cancellation of a prior claim.  
 
We looked at the file and Medicare rules. In this case, we confirmed that the claim in question for the injection 
services included a field for a frequency code, which was reported as 8. Frequency code 8 indicates the 
intention to void or cancel a prior claim. This means that the claim is a void of a previously submitted claim. Payment cannot be made for a claim with a frequency code of 8. As such, the denial of the injection services is 
appropriate. Based on this information, we decided that Medicare rules for coverage of the injection services 
have not been met. Therefore, we decided that the Plan does not have to pay for the injection services described 
by codes 96372, J0223, and J0223-JW billed for date of service February 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each office visit provided on May 18, 2023, 
to July 24, 2023. 
 
You asked the Plan to waive the copayment for each office visit. You say that you did not see a doctor. 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 $15 
copayment for each Medicare-covered specialist visit. 
 
You have been asked to pay a $15 copayment for each office visit. This item/service falls within the each 
Medicare-covered specialist visit 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 amount you owe is $45 ($15 copayment x 3 visits = $45). Therefore, 
we decided that the Plan does not have to waive the copayment for each office visit provided on May 18, 2023, 
to July 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic supplies provided on July 1, 2023. 
 
You asked the Plan to pay for the diabetic supplies. You say that you do not agree with the denial of payment, 
we have sent all the appropriate documents. The Plan denied your request. The Plan says you are not enrolled 
in Medicare as a durable medical equipment supplier. Therefore, the claim was denied. 
 
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 you not enrolled in the Medicare program. Therefore, we 
decided that the Plan does not have to pay for the diabetic supplies provided on July 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87532, 87502, 87486, 87496, 87498, and 
87634 billed for date of service April 29, 2023. 
 You asked the Plan to pay for procedure codes 87532, 87502, 87486, 87496, 87498, and 87634. You say that 
you disagree with the denial. The Plan denied your request. The Plan says payment for codes 87532, 87502, 
87486, 87496, 87498, and 87634 is bundled into payment for code 87150. 
 
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 
87532, 87502, 87486, 87496, 87498, and 87634 are column II codes to column I code 87150. The -59 modifier 
is not supported as a separate and distinct procedural service. 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 
87532, 87502, 87486, 87496, 87498, and 87634 billed for date of service April 29, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the individual psychotherapy visits (90837) provided April 
17, 2023, to July 26, 2023. 
 
You asked the Plan to pay for the psychotherapy visits. You say that you live on your pension and social 
security and paid for each session in good faith. The Plan denied your request. The Plan says this provider type 
is not eligible to participate in the Medicare program.  
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 a Licensed Professional 
Counselor and is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to 
pay for the individual psychotherapy visits (90837) provided April 17, 2023, to July 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prosthetics from an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve these services. You say that the enrollee would like to continue care with 
this provider. The Plan denied your request. The Plan says the services are available from network providers. 
 
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 
prosthetics from an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 14, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. 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. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
September 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 billed for date of service June 29, 
2023. 
 You asked the Plan to pay for procedure code 99214. You say that 99214 should be paid as billed because it 
was coded accurately. The Plan denied your request. The Plan says payment for code 99214 is bundled into 
payment for code 96372. 
 
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 99214 
is a column II code to column I code 96372. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 code 99214 billed for date of service June 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inflatable tub (E1399). 
 
You asked the Plan to pre-approve the inflatable tub. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
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 an inflatable tub (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-spinal electrical osteogenesis stimulator (E0747). 
 
You asked the Plan to pre-approve an osteogenesis stimulator. You say that you are requesting reconsideration 
of authorization for a bone growth stimulator. The Plan denied your request. The Plan says the Medicare 
criteria for coverage has not been met. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone growth stimulator is covered for 
failed fusion of a joint other than in the spine where a minimum of nine months has elapsed since the last 
surgery. 
 
In this case, the record show that the enrollee had surgery August 16, 2023. There has not been a minimum of 9 months that have passed since having surgery. Therefore, we decided that the Plan does not have to pre-
approve a non-spinal electrical osteogenesis stimulator (E0747).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the colonoscopy provided on January 26, 
2023. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that you want the $300 copayment 
changed to $0. 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 $300 
copayment for outpatient hospital services. 
 
You have been asked to pay a $300 copayment for the colonoscopy. This item/service falls within the 
outpatient hospital services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
colonoscopy provided on January 26, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive audiometry threshold evaluation and speech 
recognition (92557), and outpatient clinic visit (G0268, G0463) provided on October 10, 2023. 
 
You asked the Plan to pay for comprehensive audiometry threshold evaluation and speech recognition (92557), 
and outpatient clinic visit (G0268, G0463). 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 comprehensive 
audiometry threshold evaluation and speech recognition (92557), and outpatient clinic visit (G0268, G0463) 
provided on October 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on August 29, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are asking for the medical records to be 
reviewed. 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 August 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve comprehensive orthodontic treatment  adult dentition 
(D8090). 
 
You asked the Plan to pre-approve  comprehensive orthodontic treatment  adult dentition. You say that the 
service is necessary. The Plan denied your request. The Plan says the requested service is not covered. 
 
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 pre-approve 
comprehensive orthodontic treatment  adult dentition (D8090).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (80048, 80076, 81003, 83735, 85027) 
provided on July 27, 2023. 
 
You asked the Plan to pay for laboratory services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a PC/TC Indicator of 9 indicates that the concept 
of a professional/technical component does not apply. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, the services at issue were reported with 
modifier 26, indicating the professional component of the services. However, the services at issue have PC/TC 
indicators of 9. The use of modifier 26 is not appropriate with these codes.  
  Therefore, we decided that the Plan does not have to pay for laboratory services (80048, 80076, 81003, 83735, 
85027) provided on July 27, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a computed tomography (CT) scan 
provided on September 14, 2023. 
 
You asked the Plan to reduce the copayment for a computed tomography (CT) scan. You say that you were told 
there would be a $55 copayment, not $225. 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 $225 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $225 copayment for a computed tomography (CT) scan. 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. Therefore, we decided that the Plan 
does not have to reduce the copayment for a computed tomography (CT) scan provided on September 14, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 81225 billed for date of service June 27, 2023. 
 
You asked the Plan to pay for the billed code. You say that the test is a covered benefit. The Plan denied your 
request. The Plan says that only a single code should be reported. 
 
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. 
 
We looked at the file and the rules. We find that a NeuroIDgenetix test was provided. Only one code was billed 
for this testing as required. A miscellaneous code is only required if there is no code that describes the service 
at issue. 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  Therefore, we decided that the Plan has to pay for 
procedure code 81225 billed for date of service June 27, 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 pay for a psychiatric diagnostic evaluation, and individual 
psychotherapy provided on July 03, 2023, to July 11, 2023. 
 
You asked the Plan to pay for a psychiatric diagnostic evaluation, and individual psychotherapy. You say that 
these services do not require a referral. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a psychiatric diagnostic 
evaluation, and individual psychotherapy provided on July 03, 2023, to July 11, 2023.