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

 
We decided that the Plan does not have to waive the copayments for the ultrasounds on July 24, 2023, to July 
25, 2023.  
 
You asked the Plan to waive the copayments for the ultrasounds. You say that you shouldn't be assessed the 
cost share because you were informed that there wouldn't be a 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 $10 
copayment for primary care provider. You must pay a $20 copayment for specialty care physician. For both 
services its $10 + $20 = $30. Therefore, results in the total cost sharing amount of $30. 
 
You have been asked to pay a $30 cost share for the ultrasounds. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and 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. Therefore, we decided that the Plan does not have to waive the 
copayments for the ultrasounds on July 24, 2023, to July 25, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on July 10, 2022 to August 8, 
2022. 
 
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
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 the home health services are not supported in the medical record. Specifically, the date of 
admission on the claim billed does not match the admission date on the Notice of Admission. 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 on July 10, 2022 to 
August 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound infection panel provided on September 19, 2022. 
 
You asked the Plan to pay for the wound infection panel. You say that the provided wound infection panel was 
medically necessary. The Plan denied your request. The Plan says the enrollee did not meet criteria for the 
provided wound infection panel.  

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 the wound infection panel. Our reviewer 
says that the enrollee did not meet criteria for the provided wound infection panel. Our physician reviewer has 
determined that the wound infection panel does not meet Medicare rules because the testing is not Food and 
Drug Administration (FDA) approved nor has the testing undergone registration with the Molecular Diagnostic 
Services Program (MolDX). The review has determined that the enrollee does not meet the above LCD criteria 
for the provided wound infection panel. 
 
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 wound infection panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the wound infection panel provided on September 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the Part B drugs and myocardial perfusion 
on June 21, 2023. 
 
You asked the Plan to reduce the cost share for the Part B drugs and myocardial perfusion. You say that you 
feel the copayment should 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 for chemotherapy drugs, infusion drugs, and all other drugs covered under Medicare Part B. You 
must pay a $75 copay for diagnostic procedures and tests, including ultrasounds, at all locations of service. For 
both services it's $75 + $43 = $118. Therefore, results in the total cost sharing amount of $118. 
 
You have been asked to pay a 20% coinsurance for the Part B drugs and a $75 copayment for myocardial 
perfusion. This item/service falls within the Medicare Part B prescription drugs and outpatient diagnostic tests 
and therapeutic services and 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. Therefore, we decided that the Plan does not have to reduce the cost share for 
the Part B drugs and myocardial perfusion on June 21, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided July 13, 2023. 
 
You asked the Plan to pay for the ambulance service. You say that you were released from the hospital could 
not walk. You had to be transported home with help. You did not know should have asked for a 
predetermination.  The Plan denied your request. The Plan says neither Medicare nor the Plan pays for this 
service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 13, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided July 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the Part B drugs and an office visit on July 
25, 2023. 
 
You asked the Plan to reduce the cost share for the Part B drugs and an office visit. You say that you are asking 
for assistance to reduce the payment since you are on a fixed income. 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% 
coinsurance of the total cost for other Medicare-covered Part B drugs. You must pay a $40 copay for each 
Medicare-covered visit with a specialist. The provider billed in the amount of $2,060 and the allowed amount is 
$692.75. For the service it's $692.75 x 40% = $277.10. For both services it's $40 + $277.10 = $317.10. 
Therefore, results in the total cost sharing amount of $317.10. 
 
You have been asked to pay a 40% coinsurance for the Part B drugs and a $40 copayment for an office visit. 
This item/service falls within the Medicare Part B prescription drugs and 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 reduce the cost share for 
the Part B drugs and an office visit on July 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0452, 87471, 87481, 87551, 87651, 87653, 
87500, 87641, 87798) provided on September 29, 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 cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.   
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for lab services (G0452, 87471, 87481, 87551, 87651, 87653, 87500, 87641, 87798) 
provided on September 29, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 73130 and 96372 provided on August 14, 
2023. 
 
You asked the Plan to pay for procedure codes 73130 and 96372. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the billed codes are 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 CPT code. 
 
We find that CPT codes  73130 and 96372 are not supported in the medical record. Specifically, the billed 
codes have a status indicator of Q1 and were billed on the same date of service as code 99284 that has a status 
of V. Codes 73130 and 96372 are packaged and not separately payable. Based on this information, we decided 
that Medicare rules for coverage of procedure codes 73130 and 96372 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 73130 and 96372 provided on August 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried and failed 
conservative treatments without relief. The Plan denied your request. The Plan says the Intracept procedure is 
not medically necessary. 
 
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 the Intracept procedure. Our reviewer 
says that the Intracept procedure is not medically necessary. Our physician reviewer found that there is no 
magnetic resonance imaging (MRI) showing only modic changes without facet degenerative joint disease and 
the cause of pain is not clear. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) on February 1, 
2023 to February 20, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that this service was medically 
necessary. The Plan denied your request. The Plan says this item is non-covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) on February 1, 2023 to February 20, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan of aorta, inferior vena cava, iliac vasculature, 
or bypass grafts (93978) provided on September 14, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the diagnostic service. You say that you are a mobile imaging provider sent by 
the doctor to perform these services. You are sent to see patients on an urgent/emergent basis. The Plan denied 
your request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 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 the duplex scan of aorta, inferior vena cava, iliac 
vasculature, or bypass grafts (93978) provided on September 14, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 5, 2022, billed 
with codes 81314-90, 81334-90, 81345-90, 81272-90, 81479-90 GY x3, 81201-90, 81218-90, 81292-90, 
81295-90, 81298-90, 81307-90, 81317-90, 81321-90, 81162-90, 81351-90, 81209-90. 
 
You asked the Plan to pay for the genetic testing billed. You say that please have a look at the attachment and 
reconsider the charges which were previously denied. 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 
December 5, 2022, billed with codes 81314-90, 81334-90, 81345-90, 81272-90, 81479-90 GY x3, 81201-90, 
81218-90, 81292-90, 81295-90, 81298-90, 81307-90, 81317-90, 81321-90, 81162-90, 81351-90, 81209-90.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sprint PNS system. 
 
You asked the Plan to pre-approve the sprint PNS system. You say that the sprint PNS system will be used to 
assess the enrollee's suitability for a permanent PNS implant, including their potential identification and 
disqualification as a non-responder not suitable to advance to a permanent PNS system while also identifying 
their potential to be an early or delayed responder suitable to advance to a permanent PNS system implant if 
their pain relief following the sprint implant is significant but not sustained. The Plan denied your request. The 
Plan says the sprint PNS system is not medically necessary. 
 
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 the sprint PNS system. Our reviewer 
says that the sprint PNS system is not medically necessary. Our physician reviewer found that the sprint PNS 
device is considered experimental for chronic pain and more research is needed. 
 
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 sprint PNS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the sprint PNS system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 28470 and 28490 rendered on April 8, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 the denied codes is: 
 
CPT 28470: 
 
Closed treatment of metatarsal fracture; without manipulation, each 
 
CPT 28490:  
Closed treatment of fracture great toe, phalanx or phalanges; without manipulation 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee was being treated for 
displaced fracture of proximal phalanx of right great toe. She presented to the emergency department after a 
mechanical fall in a parking lot. She has pain in the right foot/ankle. She sprained her right ankle about 1 week 
ago and was trying to get an appointment with an orthopedic doctor. She sprained her right foot again in the 
parking lot. She uses a walker on and off. The exam reveals tenderness over the right forefoot with no 
significant swelling. The right foot was wrapped with padding and Ace wrap. She was given a postop shoe. 
However, the documentation does not support that fracture care treatment was provided and the follow-up has 
not clearly occurred. Therefore, the documentation does not support that CPT 28470: closed treatment of 
metatarsal fracture; without manipulation each and CPT 28490: closed treatment of fracture great toe, phalanx 
or phalanges; without manipulation were performed in this case.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 28470 and 28490 rendered on April 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental service (D1110) on July 28, 2023. 
 
You asked the Plan to pay for the dental service (D1110). You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 25, 2023. 
Therefore, we decided that the Plan does not have to pay for the dental service (D1110) on July 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and psychotherapy provided on July 20, 2023, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient services. You say that the services were necessary for the enrollee. 
The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 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 the office visit and psychotherapy provided on 
July 20, 2023, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96372 billed for date of service October 3, 
2023. 
 You asked the Plan to pay for procedure code 96372. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 96372 is bundled into payment for code 20552. 
 
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 96372 
is a column II code to column I code 20552. 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 96372 billed for date of service October 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for crown -porcelain/ceramic tooth #5 
provided on July 13, 2023. 
 
You asked the Plan to waive the coinsurance for crown -porcelain/ceramic. You say that this should be 
covered. 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 class 3 major dental services.  
 
You have been asked to pay 50% coinsurance for crown -porcelain/ceramic. This item/service falls within the 
class 3 major dental 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 coinsurance for crown -
porcelain/ceramic tooth #5 provided on July 13, 2023.