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

 
We decided that the Plan does not have to reduce the copayment for each injection administration provided on 
February 27, 2023, to March 27, 2023. 
 
You asked the Plan to reduce the copayment for each injection administration. You say that you think that the 
enrollee should be charged less. 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 $275 
copayment for Medicare-covered surgical services performed in an outpatient department of a hospital. 
 
You have been asked to pay a $275 copayment for each injection administration. This item/service falls within the Medicare-covered surgical services performed in an outpatient department of a hospital 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 for each service is less than the standard copayment, you only owe $122.40 ($61.20 
copayment x 2 services = $122.40). Therefore, we decided that the Plan does not have to reduce the copayment 
for each injection administration provided on February 27, 2023, to March 27, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the electrical connection between the wheelchair controller and 
two or more motors (E2311), expandable controller (E2377), and harness (E2313). 
 
You asked the Plan to pre-approve the electrical connection between the wheelchair controller and two or more 
motors, expandable controller, and harness. You say that the its are medically necessary. The Plan denied your 
request. The Plan says that the items are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 the electrical connection between the 
wheelchair controller and two or more motors, expandable controller, and harness. Our reviewer says that the 
requested items are considered medically reasonable and necessary in this case. Our physician reviewer found 
the patient is functionally non-ambulatory and requires a power wheelchair for mobility and performing his 
basic daily activities. He cannot perform pressure relief independently due to upper extremity weakness and 
requires a power wheelchair with power tilt and recline for adequate pressure relief and positioning. He 
currently has a sacral pressure wound. He requires power elevating leg rests for positioning of his lower 
extremities and lower extremity spasticity. The complexity of her seating and positioning needs necessitates a 
more complex group 3 power wheelchair base. The expandable controller with harness and electronic 
connection are necessary to operate the group 3 power wheelchair base and the three power options via a 
joystick. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the electrical connection between the wheelchair controller and two or more 
motors, expandable controller, and harness have been met. Therefore, we decided that the Plan has to pre-
approve the electrical connection between the wheelchair controller and two or more motors (E2311), 
expandable controller (E2377), and harness (E2313).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory drug testing provided on March 22, 2023. 
 
You asked the Plan to pay for laboratory drug testing. You say that the plan should cover this due to COVID 19 
issues. 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 laboratory drug testing 
provided on March 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric evaluation provided on March 10, 2023. 
 
You asked the Plan to pay for the psychiatric evaluation. You say that the provider is in-network. 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 psychiatric 
evaluation provided on March 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth services provided on March 22, 2023. 
 
You asked the Plan to pay for the telehealth services. You say that you are requesting reconsideration of 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 the telehealth services 
provided on March 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 08, 2022. 
 
You asked the Plan to pay for an office visit. You say that you say that you requested to be paid as participating 
provider on claim rather than have the patient pay as out-of-network. 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 an office visit provided 
on December 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and a mammogram provided on December 28, 
2022. 
 
You asked the Plan to pay for an office visit and a mammogram. You say that you are requesting 
reconsideration of 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 an office visit and a 
mammogram provided on December 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure) (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried and failed 
conservative therapy. The Plan denied your request. The Plan says medical studies do not show that this 
procedure works better than others. 
 
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 the Intracept procedure. Our reviewer says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation does not include magnetic resonance imaging (MRI) 
showing only Modic changes without facet degenerative joint disease or stenosis. The reviewer found that the 
cause of the enrollee's pain is not clear. Therefore, the reviewer found that the requested Intracept procedure 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept procedure) 
(64628).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on April 4, 2023, billed with 5 units 
of code 83520 and 1 unit of 87798. 
 
You asked the Plan to pay for the lab testing as billed. You say that these services were medically necessary.  
The Plan denied your request. The Plan says the codes at issue are not supported by the records.  
 
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 83520 is immunoassay for analyte other than infectious 
agent antibody or infectious agent antigen; quantitative, not otherwise specified. The definition of 87798 is 
infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, 
each organism. 
 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 lab testing as billed. Our reviewer says that the codes at 
issue are not supported.  Our reviewer found these codes cannot be verified, as the lab report does not include 
documentation of specific procedures billed under these procedure codes. 
 
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 lab testing as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab testing provided on April 4, 2023, billed with 5 units of code 83520 and 1 unit 
of 87798.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81479 billed for date of service March 13, 
2023. 
 
You asked the Plan to pay for procedure code 81479. You say that this testing was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says the services provided would be more 
accurately reported with another procedure code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 81479 is unlisted molecular pathology procedure. 
 
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 procedure code 81479. Our reviewer says that code 81479 is 
not supported in the records provided. Our reviewer found the laboratory report documents a genomic sequencing procedure. In this case, the service would not be reported with an unlisted procedure code, as a 
more appropriate and specific code exists. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 81479 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 81479 billed for date of service March 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on May 19, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that the service was medically necessary. 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 laboratory service 
provided on May 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (37248) provided on May 23, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 37248 is "Transluminal balloon angioplasty (except 
dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation 
necessary to perform the angioplasty within the same vein; initial vein". 
 
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 use of code 37248 is 
not supported by the records provided. Our reviewer found that the procedure report documents, "A 12mm balloon angioplasty was then performed to remove the fibrin sheath". For CPT 37248, using an open incision 
or a percutaneous (small incision in the skin) approach, the provider places a balloontipped catheter into the 
lumen (interior) of a vein (except for the dialysis circuit) and expands the balloon as many times and at as 
many points as necessary within the same vein to open up the vein and improve blood circulation. The 
procedure includes all imaging guidance and diagnostic imaging necessary to carry out the angioplasty and all 
radiological supervision and interpretation (RS&I).  In this case, there is a more appropriate code that should be 
reported for service documented. 
 
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 the services (37248) provided on May 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20611 billed for date of service March 24, 
2023. 
 
You asked the Plan to pay for procedure code 20611. You say that this service was necessary and is supported 
as billed. The Plan denied your request. The Plan says this code is not supported in the medical record. 
 
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 20611 is arthrocentesis, aspiration and/or injection, major 
joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent 
recording and reporting. 
 
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 procedure code 20611. Our reviewer says that code 20611 is not supported in the records provided. Our reviewer found the documentation does not support permanent 
recording and reporting, and therefore this code cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 20611 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 20611 billed for date of service March 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on February 27, 2023, billed 
with procedure codes 96365-59, 96366-59 (2 units), 96521, J1817, and G0108. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 codes 96365-59, 96366-59 (2 units), 96521, J1817, and G0108 
is intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour, 
intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour 
(List separately in addition to code for primary procedure), refilling and maintenance of portable pump, insulin 
for administration through durable medical equipment (i.e., insulin pump) per 50 units, and diabetes outpatient self-management training services, individual, per 30 minutes. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found codes 96365 and 96366 are not supported 
as there is a more appropriate code to report for the service documented. Procedure report includes a physician 
order for refilling and maintenance of portable pump; however, documentation does not support the procedure 
was performed, and therefore code 96521 cannot be verified. Procedure report describes intravenous insulin 
treatment provided for an outpatient.  In this case, code J1817 would be included in the primary procedure code 
when reported correctly. Provider documents Direct counseling for 20 minutes, reinforced diet, lifestyle 
changes, medication and adherence to monitoring blood sugars, daily weights. Medicare regulations require 
that in order to be covered, diabetes self-management training must be furnished in increments of no less than 
one-half hour".  As such, code G0108 cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on February 27, 2023, billed with procedure 
codes 96365-59, 96366-59 (2 units), 96521, J1817, and G0108.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from July 5, 2022, to July 
24, 2022. 
 
You asked the Plan to pay for inpatient hospital care. You say that you have reported 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 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 inpatient hospital care have been met. 
Specifically, you have not provided an itemized bill for the services at issue. 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 inpatient hospital care provided from July 5, 2022, to July 24, 2022.