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

 
We decided that the Plan does not have to waive the cost share for an injection and a specialist office visit 
provided on July 19, 2023. 
 You asked the Plan to waive the cost share for an injection and office visit. You say that the three injections 
received should have the same cost share because they were all the same services. 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 20% 
coinsurance for Medicare Part B prescription drugs and a $20 copayment for services from a specialist.  
 
You have been asked to pay $50.88 for an injection and office visit. This total included $30.88 coinsurance, 
which is 20% of the allowed amount for a Medicare Part B injection ($154.40 allowed x 20% = $30.88) and a 
$20 copayment for an office visit. The injection falls within the Medicare Part B prescription drugs benefit 
category. The specialist office visit falls within the physician/practitioner 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 cost share for an injection and a specialist office visit provided on July 19, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve arthrodesis (22612) and an allograft (20930). 
 
You asked the Plan to pre-approve arthrodesis (22612) and an allograft (20930). You say that this is medically 
necessary. The Plan denied your request. The Plan says that this is 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 arthrodesis (22612) and an allograft 
(20930). Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has mild-moderate L2-3 spinal stenosis 
causing persistent radicular back pain for years. the enrollee has failed epidural spinal injections, physical 
therapy, heat, ice, rest and medications. There is a difference of opinion on reading the degree of subluxation in 
the dynamic films. The request is for placement of the minuteman device. The difference of opinion here is 
noteworthy, and preference should be given to the operating surgeon. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of arthrodesis (22612) and an allograft (20930) have been met. Therefore, we 
decided that the Plan has to pre-approve arthrodesis (22612) and an allograft (20930).  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing (G0299). 
 You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the clinical 
documentation does not specify any complex wounds, changes in clinical status, medications or plan of care. 
The records do not show that additional home health skilled nursing services are required to effectively provide 
treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a 
maintenance program to maintain the enrollee's condition and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing (G0299).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services (D9120 and D6245). 
 
You asked the Plan to pre-approve the dental services (D9120 and D6245). You say that you would like to 
request reconsideration of the denied dental services and that the services requested are medically necessary. 
The Plan denied your request. The Plan says the services requested are not covered benefits. 
 
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 the 
dental services (D9120 and D6245).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services coded as 99306 and 
99497 billed for date of service June 7, 2023. 
 
You asked the Plan to pay for 99306 and 99497. You say that 99306 and 99497 should be paid as billed 
because they are supported in the documentation. The Plan denied your request. The Plan says 99306 and 
99497 are denied because they are not supported in the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 99306 and 99497 are not supported in the medical record. Specifically, the records 
show an evaluation and management note that includes discussion of advance care planning dated June 8, 
2023, but the same documentation also lists the effective date range of the services as June 7, 2023. 
Consequently, there is conflicting information regarding when the exam took place, and the actual date of 
service for codes 99306 and 99497 cannot be verified. Based on this information, we decided that Medicare 
rules for coverage of 99306 and 99497 have not been met. Therefore, we decided that the Plan does not have to 
pay for the evaluation and management services coded as 99306 and 99497 billed for date of service June 7, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 19 additional chiropractic manipulative treatment visits 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve 19 additional chiropractic manipulative treatment visits with an OON 
provider. You say that there is no network chiropractor to see that is within a reasonable distance from her 
home. The Plan denied your request. The Plan says they have approved 1 evaluation visit with the OON 
chiropractor. The Plan says that they would approve further visits if the records from that approved visit 
confirm the spinal issues the enrollee has described.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.   
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 19 additional chiropractic manipulative 
treatment visits with an OON provider Our reviewer says that the criteria for coverage have not been met. Our 
physician reviewer found the records provided report scoliosis and back pain but do not document subluxation 
of the vertebrae either by physical examination or radiologic imaging. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 19 additional chiropractic manipulative treatment visits with an OON provider 
have not been met. Therefore, we decided that the Plan does not have to pre-approve 19 additional chiropractic 
manipulative treatment visits to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 23, 2022, billed 
with codes 87500, 87641, 87795, G0452, 87471, 87481, 87551, 87651, and 87653. 
 
You asked the Plan to pay for the genetic testing billed. You say that the test aids in appropriate treatment 
decisions. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on 
the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. The file shows that a wound panel was provided. We looked at the file and Medicare rules. This NGS panel 
was not billed with a single code as required. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to 
pay for the genetic testing provided on December 23, 2022, billed with codes 87500, 87641, 87795, G0452, 
87471, 87481, 87551, 87651, and 87653.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee is physically declining and needs 
rehabilitation. You say the enrollee has not been getting the exercise they need to stay physically strong and 
will continue to decline without SNF services. The Plan denied your request. The Plan says admission to a SNF 
is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that the items should be covered as the 
enrollee disagrees with the denial. The Plan denied your request. The Plan says the items denied correctly as 
they are excluded from Medicare. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventative medicine counseling services coded as 
99402 billed on dates of service May 30, 2023, and June 6, 2023. 
 
You asked the Plan to pay for 99402. You say that 99402 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says 99402 is denied because this code has a Status 
Indicator of N on the Physician Fee Schedule. 
 
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 confirmed that CPT code 99402 has a Status Indicator of N on the Physician Fee Schedule. 
This indicator identifies codes for services that are not covered by Medicare. As such, no payment is warranted. 
Based on this information, we decided that Medicare rules for coverage of 99402 have not been met. Therefore, 
we decided that the Plan does not have to pay for the preventative medicine counseling services coded as 
99402 billed on dates of service May 30, 2023, and June 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bath/shower chair.  
 
You asked the Plan to pre-approve a bath/shower chair. You say that you had a stroke and are unable to stand 
for the period of time it takes to take a shower. You also say that you need assistance with getting out of the 
shower. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a bath/shower chair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81291 for date of service June 15, 2023. 
 
You asked the Plan to pay for procedure code 81291. You say that you disagree with the Plan's 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 procedure code 81291 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 81291 for date 
of service June 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the treatment of a root canal obstruction (D3331). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
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 the 
treatment of a root canal obstruction (D3331).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown tooth 26 (D2750). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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 August 5, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a crown tooth 26 (D2750).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary 
for your health. The Plan denied your request. The Plan says you can receive this care in another setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found You are recovering well and does not have complex wound care needs. You do not 
meet LTACH admission criteria. 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36620 for date of service June 5, 2023. 
 
You asked the Plan to pay for procedure code 36620. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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 36620 is arterial catheterization or cannulation for 
sampling, monitoring or transfusion (separate procedure); percutaneous. 
 
We find that CPT code 36620 is not supported in the medical record. Specifically, the submitted medical 
records do not indicate that arterial catheterization or cannulation for sampling, monitoring or transfusion 
(separate procedure); percutaneous was performed. Based on this information, we decided that Medicare rules 
for coverage of procedure code 36620 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 36620 for date of service June 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 21, 2023, billed with 
codes 81226, 81227, 81240, 81241, and 81328. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 21, 2023, billed with codes 81226, 81227, 81240, 81241, and 81328.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sales tax (S9999) on the approved durable medical 
equipment (DME) purchased on June 7, 2023. 
 
You asked the Plan to pay for the sales tax. You say that the service should be covered. The Plan denied your 
request. The Plan says sales tax is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not reimburse separately for sales 
tax. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the sales tax have not been met. Therefore, we decided that the Plan does not have to pay for the 
sales tax (S9999) on the approved durable medical equipment (DME) purchased on June 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99203 billed for date of service August 22, 
2023. 
 
You asked the Plan to pay for procedure code 99203. 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 the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 
We looked at the file and Medicare rules. Payment for the services at issue is included in the global surgery 
payment for the procedure (20610) provided on the same date of service. Based on this information, we 
decided that Medicare rules for coverage of the services at issue have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 99203 billed for date of service August 22, 2023.