Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options (E0953, E0955, E1007, E1012, E1028, E2300, E2311, E2313, E2361, E2377, E2607, E2620, K0040, 
K0861). 
 
You asked the Plan to pre-approve the group 3 power wheelchair with multiple power options. You say that 
this wheelchair is medically necessary. The Plan denied your request. The Plan says coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair with multiple power 
options is covered when the criteria for a group 3 power wheelchair are met AND the enrollee requires power 
tilt or recline, OR, a ventilator mounted to the wheelchair. 
 
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 group 3 power wheelchair with 
multiple power options. Our reviewer says that the requested power wheelchair is not medically necessary. Our 
physician reviewer found the documentation does not indicate that the member has any pressure injuries or 
requires intermittent catheterization of the bladder or have spasticity that would necessitate power tilt or 
recline. The requested type of power wheelchair exceeds the enrollee's needs. Since the base wheelchair is non-
covered, the accessories are also non-covered. 
 
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 group 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple 
power options (E0953, E0955, E1007, E1012, E1028, E2300, E2311, E2313, E2361, E2377, E2607, E2620, 
K0040, K0861).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 12, 2022. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on October 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 26989 billed for July 25, 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 procedure code 26989 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 26989 is unlisted procedure, hands or fingers. 
 
We find that CPT code 26989 is not supported in the medical record. Specifically, the records show that the 
enrollee had a collagenase clostridium histolyticum injection and there is a more appropriate code for the 
services. 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 procedure code 26989 billed for July 25, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on July 19, 2023, billed with 
procedure code 10060-59. 
 
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 the service at issue was not billed with the 
required modifier to allow separate payment within the global surgery period. 
 The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 
10061-59 provided on July 14, 2023. We find that the service at issue may be unrelated to the surgical 
procedure; however, the required modifier to indicate this was not used. As such, the billing rules for these 
services have not been met. Therefore, we decided that the Plan does not have to pay for practitioner services 
provided on July 19, 2023, billed with procedure code 10060-59.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88177 billed for date of service June 29, 
2023.  You asked the Plan to pay for procedure code 88177. You say that these services were reported as performed. 
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 88177 is 6. The MAI value for this code is 3. You billed 8 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 88177 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88177 billed for date of service June 29, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from August 2, 2023, to 
August 31, 2023. 
 You asked the Plan to pay for the home health services. You say that you have submitted the required NOA. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is March 5, 2023. The NOA was not received by the Plan until October 10, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from August 2, 2023, to August 31, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vertebroplasty at T8 (25510). 
 
You asked the Plan to pre-approve vertebroplasty at T8. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 vertebroplasty at T8. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested vertebroplasty at T8 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 vertebroplasty at T8 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve vertebroplasty at T8 (25510).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 10, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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 provided on February 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on August 9, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for OON practitioner services. You say that the service was medically necessary. 
The Plan denied your request. The Plan says that their original decision to deny payment was correct. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out-of-area urgent care, and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for practitioner services provided on August 9, 2023, 
by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for a gym membership provided on January 1, 2022. 
 
You asked the Plan to reimburse for a gym membership. You say that you made an advance payment on your 
gym membership. You also say you made payment during 2022, but the fitness calendar started on April 24, 
2022, to April 24, 2023, and April 24, 2023, to April 24, 2024. The Plan denied your request. The Plan says 
reimbursement requests must be received by March 31st of the following year. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only when the reimbursement requests are received before March 31st of the following year. 
 
 
  The Plans rules for coverage of gym benefits have not been met because reimbursement requests must be 
received by the Plan by no later than March 31st of the following year. Therefore, we decided that the Plan 
does not have to reimburse for a gym membership provided on January 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 08, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing 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 services 
provided on May 08, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a wearable, automatic, external 
defibrillator provided on February 28, 2023, to April 28, 2023. 
 
You asked the Plan to waive the coinsurance for a wearable, automatic, external defibrillator. You say that you 
feel you should not owe this bill. You tried to return the item. 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 durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for a wearable, automatic, external defibrillator. This 
item/service falls within the durable medical equipment and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. The total you owe is $562.70 
($3,348.99 x 20% = $669.80). $669.80 * 3 = $2,009.40 Therefore, we decided that the Plan does not have to 
waive the coinsurance for a wearable, automatic, external defibrillator provided on February 28, 2023, to April 
28, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from July 17, 2023, to July 
31, 2023/ 
 
You asked the Plan to pay for the home health services. You say that you believe you are in-network with the 
Plan. The Plan denied your request. The Plan says you are not in-network with this particular plan and you did 
not bill the required Q-code for home health services. The Plan also says that you billed with an incorrect Type 
of Bill code. 
 
The Plan must follow Medicare rules. Medicare rules say that the Type of Bill code is a 4-digit alphanumeric 
code that gives two pieces of information. The first three digits indicate the base type of bill. The fourth digit 
indicates the sequence of this bill in this particular period of care. The acceptable 4th digit options are as 
follows: 7 (to indicate a replacement of a prior claim); 8 (to indicate a void or cancel of a prior claim); and 9 (a final claim).  Y 
 
Based on this rule, you should have billed this claim with Type of Bill code 0329.  Instead, you billed this 
claim with Type of Bill code 0322, which is incorrect. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to 
pay for home health services provided from July 17, 2023, to July 31, 2023/
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on December 31, 2022. 
 
You asked the Plan to pay for the lab testing. You say that you are requesting reconsideration for the service 
provided. 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 lab testing provided 
on December 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the lab testing and radiation therapy on July 
19, 2023. 
 
You asked the Plan to waive the cost share for the lab testing and radiation therapy. You say that you dont feel 
like you are responsible for the copay because you were not told about a copay. The Plan denied your request. 
The Plan says this cost sharing was charged correctly. 
 
 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for lab services at outpatient hospital. You must pay a 20% coinsurance for radiation therapy at 
outpatient hospital. There is a $35 copayment and a 20% coinsurance. For both services it's $35 + $277.88 = 
$312.88. Therefore, results in the total cost sharing amount of $312.88. 
 
You have been asked to pay a $312.88 cost share for the lab testing and radiation therapy. This item/service 
falls within the outpatient hospital 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 the lab testing and radiation therapy on July 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a targeted genomic sequence analysis panel provided on June 
09, 2023. 
 
You asked the Plan to pay for a targeted genomic sequence analysis panel. You say that this 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 a targeted genomic 
sequence analysis panel provided on June 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 16, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration for the service 
provided. 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 office visit provided 
on May 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 22, 2022. 
 
You asked the Plan to pay for an office visit. You say that this is supported in the records. 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 July 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a hospital bed. You say that a hospital bed is medically necessary. The Plan 
denied your request. The Plan says the requested clinical documentation to support medical necessity was not 
provided. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 
 
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 a hospital bed have been met. The Plan 
made multiple attempts to obtain a standard written order and medical documentation without success. 
Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 20, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing 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 services 
provided on July 20, 2023.