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

We decided that the Plan does not have to pay for procedure code 87798 billed for date of service September 1, 
2022. 
 
You asked the Plan to pay for procedure code 87798. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 87798 is bundled into payment for codes 87150 and 
87801. 
 
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 87798 
is a column II code to column I codes 87150 and 87801. 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 87798 billed for date of service 
September 1, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept service (A0432) provided on 
December 22, 2022. 
 You asked the Plan to pay for the paramedic intercept service. You say that you feel that since you did not 
request this service and it is an automatic response with a 911 call, it should be covered by your insurance. The 
Plan denied your request. The Plan says this service is not covered. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition.  Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept service (A0432) provided on December 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - complete series of radiographic images (D0210)  
provided on February 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that it does not say you have to wait 365 days from 
the last year you received the service. 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. This benefit includes the 
requested D0210 but is limited to one per year. Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered x-rays on March 21, 2022. Therefore, this benefit was exhausted as of February 
22, 2023. Therefore, we decided that the Plan does not have to pay for intraoral - complete series of 
radiographic images (D0210)  provided on February 22, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve carpal tunnel release surgery. 
 
You asked the Plan to pre-approve carpal tunnel release surgery. 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 carpal tunnel release surgery. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found no compelling rationale is presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested carpal tunnel release 
surgery, in this case, 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 carpal tunnel release surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve carpal tunnel release surgery.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93268 and 93224 billed for date of service 
January 5, 2022. 

You asked the Plan to pay for procedure codes 93268 and 93224. You say that these services are supported in 
the medical records. The Plan denied your request. The Plan says these services are not supported for reporting 
in this case. 
 
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 93224 is a column II code to column I code 93268 with a modifier 
indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing 
criteria have not been met for code 93224. 
 
In addition, the CPT Code Manual definition of code 93268 is external patient and, when performed, auto 
activated electrocardiographic rhythm derived event recording with symptom-related memory loop with remote 
download capability up to 30 days, 24-hour attended monitoring; includes transmission, review and 
interpretation by a physician or other qualified health care professional. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 93268. Our reviewer says that this service is 
not supported in the medical record. Our reviewer found the record does not contain evidence that the external 
cardiac monitor that was placed on the enrollee for 15 days included 24-hour attendance and monitoring with 
transmission. The report represents an interpretation of the recorded data. There is a more specific code for the 
service provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 93268 and 93224 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 93268 and 93224 billed for date of service January 5, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 10, 2022, billed 
with codes 81225, 81227, 81231, 81232, 81238, 81291, 81306 and 81335. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and is 
supported in the medical record. 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 
November 10, 2022, billed with codes 81225, 81227, 81231, 81232, 81238, 81291, 81306 and 81335.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 28, 2022. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided 
on December 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anti-reflective coating (V2750) provided on January 12, 
2023. 
 
You asked the Plan to pay for the anti-reflective coating. You say that you would like to know why the anti-
reflective coating was denied. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers 1 pair of standard lenses and frames every year. 
 
 We looked at the file and the Plan's rules. The contract clearly states that anti-reflective coating is a non-
covered option. Based on this information, we decided that the Plan's rules for coverage of the anti-reflective 
coating have not been met. Therefore, we decided that the Plan does not have to pay for the anti-reflective 
coating (V2750) provided on January 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care provided on September 15, 2022. 
 You asked the Plan to pay for subsequent hospital care. You say that the enrollee was not enrolled in hospice at 
the time of service. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on September 13, 2022. The services in question were provided 
before the end of that month.  Therefore, we decided that the Plan does not have to pay for subsequent hospital 
care provided on September 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied authorization. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the bone biopsy surgery provided on 
November 07, 2022. 
 
You asked the Plan to waive the coinsurance for the bone biopsy surgery. You say that if this had been in-
network it would have only cost $250. 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 50% 
coinsurance for out-of-network outpatient surgery. 
 
You have been asked to pay 50% coinsurance for the bone biopsy surgery. This item/service falls within the 
out-of-network outpatient surgery 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 $2,777.49 ($5.554.98 allowed amount  x 50% coinsurance 
= $2,777.49). Therefore, we decided that the Plan does not have to waive the coinsurance for the bone biopsy 
surgery provided on November 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for in-network tests and audiology services 
provided on January 23, 2023. 
 
You asked the Plan to waive the copayment for in-network tests and audiology services. You say that this was 
supposed to be routine tests and not diagnostic. 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 $100 
copayment for diagnostic procedures and tests. 
 
You have been asked to pay a $100 copayment for in-network tests and audiology services. This item/service 
falls within the diagnostic procedures and tests 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 in-network tests and audiology services provided on January 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says this service is not a covered benefit 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 pre-approve a 
mandibular partial denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retreatment of previous root canal therapy-molar 
(D3348), post removal (D2955), and the cone beam computed tomography (CT) capture and interpretation with 
limited field of viewless than one whole jaw (D0364) provided on January 2, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says the dental services were received from 
an out-of-network, unassigned dental provider, and are not covered by your supplemental 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. 
 
  
 
 
The record shows you received the dental services from an out-of-network, unassigned dental provider. Though 
the Plan offers a dental benefit in excess of Medicare coverage, dental services are not covered under this 
benefit when received from an out-of-network, unassigned dental provider. Therefore, we decided that the Plan 
does not have to pay for the retreatment of previous root canal therapy-molar (D3348), post removal (D2955), 
and the cone beam computed tomography (CT) capture and interpretation with limited field of viewless than 
one whole jaw (D0364) provided on January 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy. 
 
You asked the Plan to pre-approve HBO therapy. You say that you want to appeal this denial. The Plan denied 
your request. The Plan says the HBO therapy is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that continued treatment with HBO therapy is not covered 
if measurable signs of healing have not been demonstrated within any 30-day period of treatment. 
 
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 HBO therapy. Our reviewer says that 
the requested for HBO therapy is not medically necessary. Our physician reviewer found the provided 
documentation indicates a 30-day trial (20 sessions) of HBO therapy was approved. The reviewer found that 
the provided documentation did not clearly show the enrollee's nutritional status, how controlled their diabetes 
is, how they are offloading the toe/foot, or how severe the vascular disease is in the left foot to determine if 
HBO would likely be helpful or not. Therefore, without sufficient support made, the request for HBO therapy 
is not medically reasonable or necessary at this time.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen (HBO) therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication-assisted treatment, methadone provided on 
November 28, 2022. 
 
You asked the Plan to pay for medication-assisted treatment, methadone. You say that the services should be 
covered. 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 medication-assisted 
treatment, methadone provided on November 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for The Avise CTD test (0312U) provided June 1, 2022. 
 
You asked the Plan to pay for laboratory services. You say that please see the attached documents and below 
information regarding the test that was deemed medically necessary by the enrollee's physician. The Plan 
denied your request. The Plan says this testing does not meet coverage criteria.  
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 pay for laboratory services. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case.  Our physician 
reviewer found the Avise CTD test was requested which combines serological markers to achieve a differential 
diagnosis of lupus vs. other diseases. However, this broad list of antibody tests in one panel has not been shown 
to be more effective with confirming a diagnosis over a shorter list of tests based on currently available studies. 
The approved tests can begin the process of diagnosis for this enrollee. However, the remaining tests in this 
panel will be considered not medically necessary at this time.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does 
not have to pay for The Avise CTD test (0312U) provided June 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visits provided on February 01, 
2022, to December 20, 2022. 
 
You asked the Plan to waive the copayment for office visits. You say that you are disputing the share cost. 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 $180 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $180 copayment for office visits. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 office visits provided on February 01, 2022, to December 20, 2022.
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 the services are medically necessary for 
the enrollee's medical needs.  The Plan denied your request. The Plan says the enrollee can stay in the hospital 
until they are safe for transfer or discharge.  
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care 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 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.