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

 
We decided that the Plan does not have to pay for the dual-energy x-ray absorptiometry (DXA) bone density 
study (77080) provided on June 12, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the diagnostic services. You say that you are asking for review of the attached 
information to include the medical records that pertain to the services rendered and reprocess your claim for 
payment. 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 dual-energy x-ray absorptiometry (DXA) bone 
density study (77080) provided on June 12, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an examination for driving license provided on August 21, 
2023. 
 
You asked the Plan to pay for the examination for driving license. You say that you were seen to have the 
doctor fill out a form for the Wisconsin DOT. The Plan denied your request. The Plan says the requested 
service is not covered under your Plan. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, an examination for driving license, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for an examination for driving license provided on August 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service July 16, 
2023. 
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to One, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 is a column two code to column one code 81455 with a modifier indicator of 0. The column two code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note 
that the NCCI indicator change that you reference was not officially implemented until October 1, 2023. This 
date is well after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the 
right to submit the claim again for additional consideration based on the rule change. Therefore, we decided 
that the Plan does not have to pay for procedure code 81456 billed for date of service July 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on June 14, 2023. 
 
You asked the Plan to pay for wound care supplies. You say that these supplies are a separately billable 
expense that do not require authorization. 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 wound care supplies 
provided on June 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing (87481 and 87798) provided on February 
14, 2023. 
 
You asked the Plan to pay for procedure codes 87481 and 87798. 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 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 panel testing (87481 and 87798) provided on February 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided on August 11, 2022, to 
October 26, 2022. 
 
You asked the Plan to pay for the acupuncture services. You say that you have major back issues, and the 
recommended acupuncturist has been helping a lot. The Plan denied your request. The Plan says the 
acupuncture services were provided by an unqualified provider. 
 
  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the provider is not and was not supervised by a 
physician, physician assistant, or nurse practitioner/clinical nurse specialist. Therefore, we decided that the Plan 
does not have to pay for the acupuncture services provided on August 11, 2022, to October 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a retainer crown (D6740/D6752) for tooth #29 and #31 
provided on August 15, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this dental 
work. The Plan denied your request. The Plan says your annual dental allowance amount 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 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 the requested item or service was exhausted on date of service August 15, 2023. Therefore, we decided that the Plan does not have to pay for a retainer crown (D6740/D6752) for tooth #29 and 
#31 provided on August 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on July 17, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the drug testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing is not covered when provided OON. 
 
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 drug testing provided on July 17, 2023, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory panel provided on August 15, 2023, and 
billed with codes 87481, 87640, 87651, 87653, and 87798. 
 
You asked the Plan to pay for the respiratory panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
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 respiratory panel provided on August 15, 2023, and billed with codes 87481, 
87640, 87651, 87653, and 87798.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that these are medically necessary. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood count; complete (CBC), automated (Hgb, Hct, 
RBC, WBC and platelet count) and automated differential WBC count (85025) provided May 30, 2023. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the service have been met. Current 
Procedural Terminology (CPT) code 85025 (1 units) remains not supported. The documentation submitted did 
not include a valid physician order/lab requisition or medical records supporting provider intent to order the 
test billed; therefore, the billed code cannot be verified. Therefore, we decided that the Plan does not have to 
pay for the blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated 
differential WBC count (85025) provided May 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to lower the copayment for an eye appointment with diagnostic testing 
 
You asked the Plan to lower the copayment for an eye visit with tests. You say this was a true charge as there 
are copayments for serveral  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 up to a 
$50 copayment  for vision care and eye care.  
 
You have been asked to pay up to a $50 copayment for an eye visit with tests. This item/service falls within the 
vision care and eye care 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 lower the copayment for an eye 
appointment with diagnostic testing
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on May 11, 2023. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you were told that this service was 
part of your annual exam. 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 $35 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $35 copayment for the ultrasound. 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. However, since the allowed amount is less than the standard copayment, you only owe $13.65. Therefore, we decided that the Plan does not have to waive the copayment 
for the ultrasound provided on May 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the air-immersion therapy mattress (E1399). 
 
You asked the Plan to pre-approve the air mattress. You say that your wound will open back up if you have to 
get a regular bed The Plan denied your request. The Plan says this request is not medically necessary because 
your records show you do not have documentation of irreparable damage to your bed that necessitates 
replacement.  
 
The Plan must follow Medicare rules. Medicare rules say that, in no case can the RUL of equipment be less 
than 5 years. The rules also say that replacement due to wear is not covered during the RUL of the equipment.  
 
The item being requested shows to be for replacement of an identical or nearly identical item, due to wear. The 
case file shows that the existing equipment is less than 5 years old. This means that replacement of this equipment due to wear is not covered at this time. Therefore, we decided that the Plan does not have to pre-
approve the air-immersion therapy mattress (E1399).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
June 14, 2023, to July 5, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that during your hospital 
stay you were not in the intensive care unit. 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 $180 
copayment each day for days 1 to 5, $0 copayment for days 6 and beyond for the inpatient hospital care.  
 
 The enrollee has been asked to pay a$180 copayment each day for days one to five of the inpatient hospital 
stay. The enrollee has been asked to pay a total of $900 ($180 copayment x 5 days = $900). The enrollee was 
not charged beyond the fifth day. This item/service falls within the inpatient hospital care 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 inpatient hospital stay provided from June 14, 2023, to 
July 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the office visit. You say that you cannot find a provider that can help you 
with this operation. The Plan denied your request. The Plan says you must receive your care from a network 
provider. 
 
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 item/service at issue in this appeal. We found no exception that would require 
the Plan to pre-approve this item/service. Therefore, we decided that the Plan does not have to pre-approve the 
office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on October 12, 
2022. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that you are requesting reconsideration 
for the denied claim. 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 subsequent nursing 
facility care provided on October 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for venipuncture services provided on April 18, 2023. 
 
You asked the Plan to pay for venipuncture services. You say that you are requesting reconsideration for the 
denied claim. 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 venipuncture services 
provided on April 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on July 26, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on July 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the ankle brace and ankle  foot brace 
provided on July 5, 2023. 
 
You asked the Plan to waive the coinsurance for the ankle brace and ankle  foot brace. You say that you 
should only have to pay the copayment for the office visit and nothing else. 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 Medicare-covered items.  
 
  You have been asked to pay a total of $56.55 for the ankle brace and ankle  foot brace.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
July 5, 2023 Ankle brace $98.08 20% $19.62 
July 5, 2023 Ankle  foot brace $184.67 20% $36.93 
TOTAL:    $56.55 
 
These items/services fall within the durable medical equipment (DME) and related supplies benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for the ankle brace and ankle  foot brace provided on July 5, 
2023.