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

 
We decided that the Plan does not have to pay for the office visit (99203), x-ray (73130), and injection (20550) 
provided on March 22, 2023. 
 
You asked the Plan to pay for the office visit (99203), x-ray (73130), and injection (20550). 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 the office visit (99203), 
x-ray (73130), and injection (20550) provided on March 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that the enrollee has edema to lower 
extremities with right greater than left, minor skin and soft tissue bleeding and cold extremities. You also say 
that the compression stockings will prevent further skin breakdown or other complications due to the patient's 
body habitus. The Plan denied your request. The Plan says this request does not meet Medicare requirements 
for approval.  
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 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 A6530.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99000 billed for date of service May 31, 
2023. 
 
You asked the Plan to pay for procedure code 99000. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says procedure code 99000 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 99000 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99000 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99000 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99000 billed for date of service May 31, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laparoscopy, surgical, colpopexy and laparoscopy, surgical, 
supracervical hysterectomy provided on June 13, 2023. 
 
You asked the Plan to pay for laparoscopy, surgical, colpopexy and laparoscopy, surgical, supracervical 
hysterectomy. You say that the services were medically necessary. The Plan denied your request. The Plan says 
only certain providers can enroll in Medicare and this providers specialty and taxonomy does not have the 
capacity to bill directly for the services rendered. The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for laparoscopy, surgical, colpopexy and 
laparoscopy, surgical, supracervical hysterectomy provided on June 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided on June 13, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. 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 the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services (81479) provided on 
June 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 17, 2023, billed with 
procedure code 99204. 
 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 diagnosis code at issue is not appropriate as a 
primary diagnosis. 
 
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code G65.0, described 
as sequelae of Guillain-Barre syndrome. This code is not an appropriate primary diagnosis as the code has a 
code first note indicating to code the underlying condition first. Based on this information, we decided that 
Medicare rules for payment of this claim have not been met. Therefore, we decided that the Plan does not have 
to pay for practitioner services provided on March 17, 2023, billed with procedure code 99204.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient behavioral health admission. 
 
You asked the Plan to pre-approve inpatient behavioral health admission. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active 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 inpatient behavioral health admission. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon 
review of the records provided, this enrollee does not meet criteria for acute inpatient mental health treatment 
as this enrollee was not shown to be a danger to himself or others. No auditory or visual hallucinations were 
noted. He is noted to be cooperative and compliant with treatment while not showing any aggressive behaviors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient behavioral health admission have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient behavioral health admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service July 11, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99100 is considered bundled and not separately payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service July 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4342). 
 
You asked the Plan to pre-approve periodontal scaling and root planing. You say that you were told that you 
have periodontitis, and it needs to be treated before they find out if the teeth need to be extracted. The Plan 
denied your request. The Plan says this is not a covered service under this 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 
periodontal scaling and root planing (D4342).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99215), handheld low vision aids (V2600) 
and prism lenses (V2715) provided on May 4, 2023. 
 
You asked the Plan to pay for an office visit (99215), handheld low vision aids (V2600) and prism lenses 
(V2715). You say that you have submitted records verifying the frames are medically necessary. The Plan 
denied your request. The Plan says this benefit has been exhausted. 
 
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 one eye examination and $150 towards the cost of eyewear each year. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan covers one routine eye examination 
per year. The Plan rules also say they will reimburse $150 towards the purchase of eyeglasses or contact lenses. 
The record shows the benefit for the routine eye examination was exhausted on another claim for the same date 
of service May 4, 2023. The record also shows that the benefit for the eyewear allowance was exhausted on 
date of service January 25, 2023. Based on this information, we decided that the Plan's rules for coverage of an 
office visit (99215), handheld low vision aids (V2600) and prism lenses (V2715) have not been met. Therefore, 
we decided that the Plan does not have to pay for an office visit (99215), handheld low vision aids (V2600) and 
prism lenses (V2715) provided on May 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Life2000, using code E0466 for a non-invasive 
ventilator (NIV). 
 
You asked the Plan to pre-approve Life2000 ventilator. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested device 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 Life2000 ventilator. Our reviewer says 
that the documentation does not support that the requested device is medically reasonable or necessary. Our 
physician reviewer found the enrollee has usual interstitial pneumonia and COPD, both of which cause 
continued lung deterioration. The enrollee does not have documented trial or failure of CPAP or BIPAP 
therapies. The enrollee does not have substantial documentation or data to support home ventilator. Therefore, 
the enrollee does not meet criteria for the requested device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Life2000 ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Life2000, using code E0466 for a non-invasive ventilator (NIV).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the records provided support medical necessity. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the records provided for review indicated 
a diagnosis of dementia. However, the records did not readily demonstrate that the member met criteria for 
either AD or FTD, let alone both. Other causes of memory impairment were not ruled out based on the records 
provided for review. 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed for date of service May 28, 
2023. 
 
You asked the Plan to pay for procedure code 99140. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99140 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 99140 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99140 billed for date of service May 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483, 80307) provided on May 11, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes G0483, & 80307 are not supported in the medical record. Specifically, no lab results 
were provided to support the billed code. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services (G0483, 80307) provided on May 11, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility admission provided January 5, 
2022, to January 14, 2022. 
 
You asked the Plan to pay for the skilled nursing facility admission. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the skilled nursing facility admission was not filed until July 17, 2023. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the skilled nursing facility admission provided 
January 5, 2022, to January 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the back brace on August 8, 2023. 
 
You asked the Plan to waive the coinsurance for the back brace. You say that you were advised by the provider 
that your cost share would be $50. 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 20% 
coinsurance of the Medicare-allowable amount for each Medicare-covered item for durable medical equipment 
(DME) and related supplies.  
 
 You have been asked to pay a 20% coinsurance for the back brace. This item/service falls within the durable 
medical equipment (DME) 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 record shows you made a partial payment of $50 to the 
provider and the Plan confirmed the provider adjusted off the remaining balance as a hardship adjustment. 
Therefore, we decided that the Plan does not have to waive the coinsurance for the back brace on August 8, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for the office visits on May 24, 2022, to August 15, 2022.  
 
You asked the Plan to reimburse for the office visits. You say that you were billed for the copay after you 
reached your out-of-pocket amount.  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 $40 
copayment for each covered visit or consultation in an outpatient location with a specialist. 
 
 
 You have been asked to pay a $40 copayment for each office visit. 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 reimburse for the office visits on May 24, 2022, to August 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat lift chair. 
 
You asked the Plan to pre-approve a power seat lift chair. You say that the item is necessary. The Plan denied 
your request. The Plan says the enrollee current has a power seat lift chair they are using. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has a power seat lift chair. Therefore, we decided that the Plan does not have to 
pre-approve a power seat lift chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 receiver. 
 
You asked the Plan to pre-approve the Dexcom G7 receiver. You say that the CGM is a medical necessity. The 
Plan denied your request. The Plan says no medical reason was provided regarding why you can't continue to 
use the Freestyle Libre system. 
 The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers.  
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand for a 
CGM receiver. Based on this information, we decided that Medicare rules for coverage of the Dexcom G7 receiver 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G7 receiver.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 2, 2023, by 
an out-of-network (OON) provider.  
 You asked the Plan to pay for nursing facility care. You say that the enrollee was residing in a nursing facility 
at the time of service. 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 subsequent nursing facility care provided on May 
2, 2023, by an OON provider.