Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on 
December 6, 2022, to December 13, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
copayment. 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 $250 
copayment per day for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a $250 copayment per day for days 1-5 for inpatient hospital care. You are being 
asked to pay $250 per day for days 1-5. The total amount you are being asked to pay is $1,250 ($250 x 5 days = 
$1,250). 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 inpatient hospital care provided on December 6, 2022, to December 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81345) provided on October 25, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like the plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (81345) provided on October 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crowns (D2740x3) and the core build-ups 
(D2950x2) 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee has recurrent decay, severe 
abrasion and enamel wear due to acid reflux. You say the full coverage of the crowns and core build-up are 
required to treat and prevent more complications. 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 Plan's 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 services have been exhausted. This plan authorized three core build-ups 
and one crown (D2740) for June 12, 2023, to December 12, 2023. Please note, the plan had previously 
approved a crown on tooth #28. Therefore, we decided that the Plan does not have to pre-approve the crowns 
(D2740x3) and the core build-ups (D2950x2)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A9279 billed for date of service November 
29, 2022. 
 
You asked the Plan to pay for procedure code A9279. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes.  
 
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 A9279 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code A9279 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code A9279 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code A9279 billed for date of service November 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit system (K0108). 
 
You asked the Plan to pre-approve a transit system. You say that the medical documentation supports the need 
of the custom medical equipment being requested for the enrollee. The Plan denied your request. The Plan says 
the requested transit option is not for primarily medical use, nor it is for in home use. The Plan also says this 
item still does not meet the coverage criteria. 
 
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 transit system (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97112 and 97530 billed for date of service 
September 28, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed codes 
cannot be verified. 
 
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 97112 and 97530 are not supported in the medical record for the date of service at 
issue. Based on this information, we decided that Medicare rules for coverage of the billed services have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 97112 and 97530 billed 
for date of service September 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unattended sleep study (95806) from July 14, 2022. 
 
You asked the Plan to pay for an unattended sleep study. You say that this was medically necessary. The Plan 
denied your request. The Plan says this is not a covered service. 
 
The Plan follows Medicare rules. 
 
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 an unattended sleep study. Our reviewer 
says that you do not meet criteria for coverage of this service. Our physician reviewer found the provided 
records in this case do not document the scoring information required. Additionally, the records do not 
document that you did not have any of the exclusionary conditions as listed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an unattended sleep study have not been met. Therefore, we decided that the 
Plan does not have to pay for an unattended sleep study (95806) from July 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel billed with code 80050 for date of 
service October 11, 2022. 
 
You asked the Plan to pay for the general health panel. You say that you have supplied medical records to show 
the necessity of this service. The Plan denied your request. The Plan says general health panels are not covered. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
 You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel 
billed with code 80050 for date of service October 11, 2022.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to reimburse you more for the cataract surgery. We decided that the Plan does not 
have to reimburse the full $178.09 you are requesting.  
 
You asked the Plan to reimburse you more cataract surgery you had on September 21, 2022. You say that you 
have been under-reimbursed by the Plan in the amount of $178.09. The Plan says that it has overturned its 
decision to charge you a second $100 copayment, but the remaining reimbursement is correct. 
 
We decided that the Plan has to reimburse you $53.03 more for the cataract surgery.  
 
The Plan follows Medicare rules. Medicare rules say that when you go to a non-Plan provider, the Plan must 
pay for services in the amount equal to the Medicare-allowed amount for these services. In this case, it appears 
as though the Plan used an incorrect fee schedule when calculating the Medicare-allowed amount for the 
cataract surgery you had.  According to the fee schedule for Maryland on the date of service, the allowed 
amount for the physician's portion of the surgery was $558.86.  The Plan has paid you $405.85, plus the $100 
copayment it says it charged incorrectly, for a total of $505.85.  There is still a difference of $53.03 between 
what the Plan has reimbursed you and the Medicare-allowed amount, and the Plan is responsible for that 
difference. Therefore, we decided that the Plan has to reimburse you an additional $53.03.  
 
We also decided that the Plan does not have to reimburse you the full $178.09 you requested. 
 
As noted above, the Plan is only required to pay up to the Medicare-allowed amount for services rendered.  In 
this case, the Medicare-allowed amount is $558.86, not $505.85 as the Plan alleges. Please note that we 
understand that a previous surgery may have been paid differently.  It is possible that surgery was billed 
differently, or with different codes that have a different Medicare-allowed amount.  In any event, that other 
claim is not before us, so we can only render a decision on the September 21, 2022, date of service. As per the 
calculation above, we find that the Plan has under-reimbursed you in the amount of $53.03 (plus, the additional 
$100 copayment that the Plan has already agreed to remove.) Therefore, we decided that the Plan does not have 
to reimburse the full $178.09 you have requested. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 94761 billed for date of service July 21, 
2022. 
 
You asked the Plan to pay for procedure code 94761. You say that you have correctly billed the service at 
issue. The Plan denied your request. The Plan says procedure code 94761 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 94761 has a status indicator of T on the Physician Fee Schedule. The case record 
documents that other services billed on the same date by the same provider have been paid by the Plan. This 
means that procedure code 94761 is not separately payable. Based on this information, we decided that 
Medicare rules for coverage of procedure code 94761 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 94761 billed for date of service July 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second unit of procedure code A4253 billed for date of 
service January 3, 2022.  
 
You asked the Plan to pay for a second unit of procedure code A4253. You say that you have correctly billed 
the items at issue. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code A4253 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code A4253 have not been met. Therefore, we decided that the 
Plan does not have to pay for a second unit of procedure code A4253 billed for date of service January 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466) (9 units). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says the ventilator is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found the record indicates that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The provided primary source documentation does not contain sufficient detailed 
information in the medical record to justify the treatment selected. The enrollee could be treated with a bilevel 
positive airway pressure (BiPAP) machine with average volume-assured pressure support (AVAPS) capability 
and failure of such a device has not been documented. The elements of the coverage criteria are not satisfied. 
The requested service cannot be recommended. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (E0466) (9 units).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoskeletal ankle foot system (L5973). 
 
 You asked the Plan to pre-approve an endoskeletal ankle foot system. You say that the enrollee benefited 
greatly from the microprocessor ankle foot unit, and should qualify for this type of technology. The Plan denied 
your request. The Plan says while documents show that the enrollee has K3 potential, the notes do not give any 
medical reason why the enrollee requires a microprocessor foot. The Plan also says no medical reason is given 
why a mechanical K3 foot will not meet enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that a microprocessor-controlled ankle foot system 
(L5973) is covered for beneficiaries whose functional level is 3 or above. 
 
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 an endoskeletal ankle foot system. Our 
reviewer says that an endoskeletal ankle foot system (L5973) is not medically necessary. Our physician 
reviewer found the physician documentation does not discuss the prosthetist's claims of the enrollee's need for 
the microprocessor foot. Our reviewer also found that the foot exceeds the enrollee's functional needs, and the 
physician documentation does not support that the enrollee's needs cannot be met with a mechanical K3 foot.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an endoskeletal ankle foot system have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an endoskeletal ankle foot system (L5973).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flex-walk system or equal (L5981). 
 
You asked the Plan to pre-approve a flex-walk system or equal. You say that you would like the Plan's decision 
to be overturned. The Plan denied your request. The Plan says the requested K3 components exceed the 
enrollee's needs and cannot be covered. The Plan also says the notes do not show why the enrollee's needs 
cannot be met with current K2 foot.  

The Plan follows Medicare rules. Medicare rules say that a flex-walk system or equal (L5981) is covered for 
beneficiaries whose functional level is 3 or above. 
 
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 a flex-walk system or equal. Our 
reviewer says that the enrollee does not meet the criteria for coverage. Our physician reviewer found the notes 
by the treating medical physician records do not corroborate that the enrollee is at least a K3 ambulator as per 
Medicare guidelines. The prosthetist is the vendor. Our reviewer found that the physician documentation does 
not discuss the enrollee's ambulatory level or support the prosthetist's claims of the enrollee's need for the 
requested items. Our physician reviewer also found that the enrollee's activities do not require a K3 level foot. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a flex-walk system or equal have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a flex-walk system or equal (L5981).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service February 9, 
2023. 
 
You asked the Plan to pay for procedure code 81345. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says payment for code 81345 is 
bundled into payment for code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 81345 billed for date of service February 9, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 2, 2023.  

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
February 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator (E0466).

You asked the Plan to pre-approve a home ventilator. You say that the enrollee will die if they do not get this machine. The Plan denied your request. The Plan says the requested device does not meet the requirements for approval.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.

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 a home ventilator. Our reviewer says that this request is not medically necessary. Our physician reviewer found the enrollee has chronic hypercapnic respiratory failure from chronic obstructive pulmonary disease. The provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment selected. Our reviewer found that the enrollee could be treated with a bilevel positive airway pressure (BiPAP) machine with average volume-assured pressure support (AVAPS) capability and failure of such a device has not been documented. The Plan has indicated coverage for such a device is available upon request. Our physician reviewer also found that the elements of the coverage criteria are not satisfied, and the requested service cannot be recommended

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator (E0466).