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

 
We decided that the Plan has to pay for procedure code 28002 rendered on February 6, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that Current Procedural Terminology (CPT) code 28002 (1 Unit ) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 28002 is ""Incision and drainage below fascia, with or without tendon sheath involvement, foot; single 
bursal space." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the enrollee was being treated for gas 
gangrene, other acute osteomyelitis right ankle/foot, type 2 diabetes Mellitus with foot ulcer, and non-pressure 
chronic ulcer of the other part of the right foot with necrosis of the bone. He underwent an incision and 
drainage of the foot on 2/6/23.  The procedure details cite the plantar wound was also debrided down to the 
bone. Therefore, the documentation does support that CPT 28002: incision and drainage below fascia with or 
without tendon sheath involvement, foot; single bursal space was performed in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
procedure code 28002 rendered on February 6, 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 29581 rendered from June 19, 2023, to July 24, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the claim does not meet coding standards. 
 
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 29581 is ""Application of multi-layer compression system; leg (below knee), including ankle and foot." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the medical documentation supports 
that this patient is suffering with a venous stasis ulceration with right lower extremity edema. The medical 
documentation supports that a 3- layer compressive Unna boot dressing was applied to the right lower 
extremity for edema reduction. Edema reduction is necessary in order to allow a venous ulceration to heal 
properly. Therefore, the documentation does support that CPT code 29581, application of multilayer 
compression system; leg (below knee), including ankle and foot was performed in this case 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
procedure code 29581 rendered from June 19, 2023, to July 24, 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from May 21, 2023, to May 
23, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you are requesting authorization and 
reimbursement for all services provided.  The Plan denied your request. The Plan says that as of May 21, 2023, 
the records show that the enrollee was hemodynamically stable with no new clinical findings and or treatments 
that would require continued inpatient stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the review indicates that the enrollee was evaluated in the emergency department May 15, 
2023, and admitted with congestive heart failure (CHF) with moderate to severe aortic stenosis. The enrollee 
was evaluated by Cardiology and underwent transcatheter aortic valve replacement (TAVR) on May 19, 2023. 
Post-operatively the enrollee tolerated the medical regimen and was evaluated by occupational therapy and 
physical therapy. The enrollee was felt stable for discharge home on May 23, 2023. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from May 21, 2023, to May 23, 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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for one additional unit of procedure code 93005 rendered on June 23, 2023.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the documentation only shows that 3 ECGs were completed on the denied date of service.

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 93005 is Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report."

We asked our 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that the enrollee underwent electrocardiogram (ECG) with 12 leads and interpretation on 6/23/23. The records showed the enrollee underwent 3 ECGs on that date. A request for 4 ECGs was made for this date. Only 3 ECGs were found as documented as completed on this date. However, there was no found documentation to verify a 4th separate ECGs from this date to support this request.

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 one additional unit of procedure code 93005 rendered on June 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for implant supported porcelain or ceramic crown (D6065) 
provided on August 9, 2023. 
 
You asked the Plan to pay for implant supported porcelain or ceramic crown. You say that you are appealing 
with supporting records. The Plan denied your request. The Plan says service 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. 
 
 
  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 implant 
supported porcelain or ceramic crown (D6065) provided on August 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for hearing aids (V5298) provided on May 26, 2023. 
 
You asked the Plan to reimburse for hearing aids. You say that the Plan representative confirmed the vendor 
was an authorized hearing aid provider. The Plan denied your request. The Plan says there is no coverage of 
hearing aids or related services if the services are not registered in advance with the Plan hearing. The Plan also 
says you must call to activate your benefit as outlined in your EOC. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the hearing aids are registered in advance with the Plan hearing.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse for 
hearing aids (V5298) provided on May 26, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the oxygen concentrator (E1390) provided from June 14, 2021, to 
November 14, 2021. 
 
You asked the Plan to pay for the oxygen concentrator. You say that you are appealing the bill of $3,500.00 
from your benefits actually paid for the oxygen concentrator to another durable medical equipment (DME) 
provider. You also say that the one DME provider went out of business, you were unaware of what was going 
on, and you no longer have the oxygen concentrator. The Plan denied your request. The Plan says that the 
claims were appropriately denied as you received the same DME supplies from multiple DME providers. The 
Plan also says the claims were billed with the same current procedural terminology (CPT) code by three 
different DME suppliers. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the Plan has not provided any evidence that the services during this 
date range were denied. The Plan also has not provided any information showing a $3,500 charge for anything. 
It is the burden of the Plan to substantiate their denial with evidence. In this case, the denial has not been 
substantiated. Therefore, we decided that the Plan has to pay for the oxygen concentrator (E1390) provided 
from June 14, 2021, to November 14, 2021.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays-four radiographic images (D0274) 
provided on August 16, 2023. 
 
You asked the Plan to pay for the dental service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 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 service provided was exhausted on date of service February 13, 2023.  
  
 
Specifically, the Plans contract states that one set of bitewing x-rays are covered per plan year. You previously 
received this service on February 13, 2023, less than one year prior, which was paid for by the Plan. Therefore, 
you have exhausted the allowable benefit for this service. Therefore, we decided that the Plan does not have to 
pay for the bitewing x-rays-four radiographic images (D0274) provided on August 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodic oral evaluation (D0120) provided on August 3, 
2023. 
 
You asked the Plan to pay for the dental services. You say that since the mouth is the host to over 600 types of 
bacteria, the examination must happen each time you go in for a cleaning so that any problems can be set up for 
correction. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 January 5, 2023. 
Therefore, we decided that the Plan does not have to pay for periodic oral evaluation (D0120) provided on 
August 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on June 5, 2023, to July 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $1,000 annual maximum 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 $1,000 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for dental services provided on June 5, 2023, to July 3, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on August 
15, 2023. 
 
You asked the Plan to pay for the ED services. You say that you are requesting the claim be reprocessed. The 
Plan denied your request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
 
 
 We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment. Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on August 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 5, 2023, billed with 
procedure code 0540T. 
 
You asked the Plan to pay for the practitioner services provided. You say that the services were pre-approved 
and should be paid. The Plan denied your request. The Plan says an explanation of benefits from the primary 
insurance carrier has not been received. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has to receive an 
explanation of benefits (EOB) from the enrollee's primary insurance carrier before this claim can be 
considered. As the secondary insurer, the Plan cannot be held responsible for the practitioner services provided 
until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not 
have to pay for practitioner services provided on April 5, 2023, billed with procedure code 0540T.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87491, 87496, 87500, 87511, 87529, 
87563, 87591, 87651, 87653, 87661, 87556, 87641 and 87798 billed for date of service June 5, 2023. 
 
You asked the Plan to pay for codes 87641 and 87798. 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 codes 87641 and 87798 have been met. 
Specifically, a physician order for code 87641 is not evident in the case record. A physician order explicitly 
noting what testing composes code 87798 is not evident in the case record. Therefore, we decided that the Plan 
does not have to pay for procedure codes 87481, 87491, 87496, 87500, 87511, 87529, 87563, 87591, 87651, 
87653, 87661, 87556, 87641 and 87798 billed for date of service June 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fluid circulating cold pad with pump provided on May 4, 
2023, through May 23, 2023. 
 
You asked the Plan to pay for a fluid circulating cold pad with pump. You say that the item in dispute was 
medically reasonable and necessary. The Plan denied your request. The Plan says the denial was appropriate 
based on Medicare guidelines. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules also say that a fluid circulating cold pad with pump will be denied as 
not reasonable and necessary.   
 
We looked at the file and Medicare rules. The item in dispute is not considered reasonable and necessary by 
Medicare. Therefore, we decided that the Plan does not have to pay for a fluid circulating cold pad with pump 
provided on May 4, 2023, through May 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat sling (K0108), multi-position fork short (K0108 
x2), spinergy blk spokes spox [Pair] (K0108 x2), 16 Inch fixed back height (K0108), backrest options: fold 
down push handles (K0108 x2), aluminum straight side guard (K0108 x2), flip back option (K0108 x2), and 
red color anodizing package (K0108). 
 
You asked the Plan to pre-approve a seat sling, multi-position fork short, spinergy blk spokes spox, 16 Inch 
fixed back height, backrest options: fold down push handles, aluminum straight side guard, flip back option, 
and red color anodizing package. You say that the items are necessary. The Plan denied your request. The Plan 
says the requested items are either not primarily medical in nature or are duplicates. 
 
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 a seat sling (K0108), multi-position fork short (K0108 x2), 
spinergy blk spokes spox [Pair] (K0108 x2), 16 Inch fixed back height (K0108), backrest options: fold down 
push handles (K0108 x2), aluminum straight side guard (K0108 x2), flip back option (K0108 x2), and red color 
anodizing package (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service August 22, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says procedure code 99100 is considered bundled and not 
separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service August 22, 2023.