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

 
We decided that the Plan has to pay for the laboratory services coded as 8481 and 87900 provided August 9, 
2022. 
 
You asked the Plan to pay for the laboratory service. You say that this test was ordered based upon the treating 
physicians clinical training and medical necessity.  The Plan denied your request. The Plan says that the 
procedure codes were not appropriate for reimbursement for the diagnosis code submitted.  
 
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 87481 is infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe 
technique and CPT code 87900 is infectious agent drug susceptibility phenotype prediction using regularly 
updated genotypic bioinformatics. 
 
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 laboratory service. Our reviewer says that the 
documentation supports the procedures in question. Our reviewer found CPT code 87481 is supported by the 
medical record as the rest results state that candida was tested for and was negative. 87900 is supported by the 
medical record as the test results contain evidence that susceptibility phenotype prediction was performed.  
 
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 laboratory service have been met. Therefore, we decided that the Plan has to 
pay for the laboratory services coded as 8481 and 87900 provided August 9, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic interface (K0108). 
 
You asked the Plan to pre-approve a wheelchair accessory. You say that you have little to no motor skills in 
your lower and upper arm. You need the ability to have a drive enhance joystick display modification for your 
wheelchair. The modification parts are needed because your condition has worsened. The Plan denied your 
request. The Plan says the requested electronic interface is experimental and cannot be covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an electronic interface (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on February 20, 2023. 
 
You asked the Plan to pay for the refraction. You say that the appointment was to follow-up for macular 
degeneration. You say this service has always been covered by insurance. The Plan denied your request. The 
Plan says the refraction is excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for the refraction provided on February 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator for 9 months (E0466). 
 
You asked the Plan to pre-approve a ventilator for 9 months. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a ventilator for 9 months. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found Provided records document 
that the home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode 
which is a modality that could be provided by a bilevel positive airway pressure (BiPAP) device with AVAPS 
and a back-up rate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator for 9 months have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ventilator for 9 months (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the apicoectomy - anterior (D3410) provided on October 27, 
2022. 
 
You asked the Plan to pay for the deep sedation/general anesthesia and apicoectomy. The Plan denied your 
request. The Plan says the apicoectomy - anterior is not covered under your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the apicoectomy - anterior (D3410) is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
apicoectomy - anterior (D3410) provided on October 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for yoga socks and blue tooth intercom headsets provided 
from November 23, 2022, to November 25, 2022. 
 
You asked the Plan to reimburse for yoga socks and blue tooth intercom headsets. You say that you feel that 
the items you submitted are very similar in purpose and character to the examples listed on the reimbursement 
form. The Plan denied your request. The Plan says the medical services/items are a non-covered service. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan will reimburse 
members up to $300 each year in total for fitness, naturopathic services, acupuncture, nutrition/dietary 
education, weight management programs, and face masks. 
 
The Plan's rules say that will reimburse members up to $300 each year in total for fitness, naturopathic 
services, acupuncture, nutrition/dietary education, weight management programs, and face masks. Yoga socks 
and blue tooth intercom headsets are not covered under this benefit. Therefore, we decided that the Plan does 
not have to reimburse for yoga socks and blue tooth intercom headsets provided from November 23, 2022, to 
November 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code P9603 billed for date of service August 25, 
2022. 
 
You asked the Plan to pay for procedure code P9603. You say that you have billed the service at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 P9603 is: Travel allowance one way in connection with 
medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; 
prorated miles actually travelled. 
 
We find that CPT code P9603 is not supported. Specifically, no documentation has been provided of miles 
traveled. Based on this information, we decided that Medicare rules for coverage of procedure code P9603 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code P9603 billed 
for date of service August 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a joystick replacement (E2374) and an attendant control 
(E2331). 
 
You asked the Plan to pre-approve a joystick replacement and an attendant control. You say that you are 
requesting reconsideration of the denied authorization. The Plan denied your request. The Plan says that the 
joystick is unbundled from the power wheelchair base and cannot be requested separately. The Plan also says 
that an attendant control is not covered when provided in addition to a beneficiary-operated control system. 
 
The Plan must follow Medicare rules. Medicare rules say that if an attendant control is provided in addition to a 
beneficiary-operated drive control system, it will be denied as non-covered. The rules also say that code E2374 
may only be used for replacements other than at the time of initial issue. 
 
We looked at the file and Medicare rules. The requested joystick cannot be approved on initial issue as code 
E2374 is for a replacement only. An attendant control is not covered when provided in addition to a 
beneficiary-operated control system. Therefore, we decided that the Plan does not have to pre-approve a 
joystick replacement (E2374) and an attendant control (E2331).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 23395 billed for date of service February 10, 
2023. 
 
You asked the Plan to pay for procedure code 23395. You say that you have billed the service at issue 
correctly. The Plan denied your request. The Plan says the provided records do not support the service 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 code 23395 is: Muscle transfer, any type, shoulder or upper 
arm; single. 
 
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 23395. Our reviewer says that procedure 
code 23395 does not meet criteria for payment. Our reviewer found that the provided record does not contain 
evidence that a muscle transfer on the upper arm was performed. 
 
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 code 23395 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 23395 billed for date of service February 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epicord, 50 units (Q4187). 
 
You asked the Plan to pre-approve wound treatment. You say that the enrollee has a wound that has been open 
for over a month and this will help him heal and lower the changes of infection. The Plan denied your request. 
The Plan says a review of the current medical literature indicates that current guidelines do not demonstrate 
that the application of Epicord is necessary for Epifix to facilitate wound healing. 
 
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 wound treatment. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical documentation supports that this enrollee is suffering with an open 
ulceration to the left hallux that has been treated with debridement, wound dressings, and offloading. Epifix 
wound dressings have been authorized by the health plan. The physician would also like to apply Epicord 
wound dressings to the wound left hallux. In this particular case, the enrollee is noted to have a recalcitrant 
ulceration to the left hallux that has not responded to conservative treatments. The health plan has authorized 
the application of Epifix to this ulceration. It is reasonable to evaluate the efficacy of Epifix prior to 
authorization of Epicord.  Therefore, the requested application of Epicord 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 wound treatment have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Epicord, 50 units (Q4187).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 22, 2022 to 
August 23, 2022.  
 
You asked the Plan to pay for the inpatient hospital services . You say that the records provided support that the 
inpatient care in dispute was medically reasonable and necessary.  The Plan denied your request. The Plan says 
after stabilization, they were not given the opportunity to transfer the enrollee to an in-network facility. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 inpatient hospital services. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found the enrollee presented to a 
non-contracted emergency department on August 22, 2022, with ED on 08/22/2022 with chest pain and 
weakness. She was evaluated and had elevated troponins. Her electrocardiogram (EKG) demonstrated sinus 
tachycardia and a chest x-ray demonstrated mild congested heart failure (CHF.) She also had evidence of a 
urinary tract infection (UTI) and was started on intravenous (IV) Rocephin. She was evaluated by Cardiology 
and given IV diuretics. She was admitted; her condition stabilized and improved, and she was discharged home 
with outpatient follow-up on August 23, 2022. The enrollee was admitted to the hospital from the emergency 
room without the required authorization from the health plan. After stabilization of the member's clinical 
condition in the emergency department, the health plan should have been given the opportunity, in a timely 
manner, to transfer the enrollee to an in-network facility, and/or involve contracted providers in the care, and/or 
provide utilization management oversight to the care the enrollee. The treating physician did not document (in 
the physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any dates of 
service. 
 
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 inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services provided on August 22, 2022 to August 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services identified with codes 87631, 94618, 
and 99072 for date of service November 29, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says these services are not payable as billed. 
 
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. The rules also say that providers must report 
services with the appropriate procedure code. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported; therefore, code 87631 is not payable as billed. In this case, we have confirmed that code 94618 is 
a column II code to column I code 94621 with a modifier indicator of 0. The column II code is therefore not 
payable. We find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This 
means that procedure code 99072 is not separately payable. 
 
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for the laboratory services identified with 
codes 87631, 94618, and 99072 for date of service November 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for date of service November 
19, 2022. 
 
You asked the Plan to pay for procedure code 99153. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this code is included in the facility payment and is not separately 
payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 3 for CPT code 99153. This means there 
is only a technical component for the CPT code. In this case, this code was billed with an inpatient hospital 
setting. This code may not be paid if furnished to hospital inpatients. This means this code is not payable as 
billed. Based on this information, we decided that Medicare rules for coverage of procedure code 99153 have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99153 billed for 
date of service November 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus Gene Panel (81455) provided on October 23, 
2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the genetic testing. You say that the enrollee's doctor regarded this test as a 
medically necessary and valuable tool when determining treatment for the enrollee. The Plan denied your 
request. The Plan says prior authorization was not obtained prior to 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 Tempus Gene Panel (81455) provided on 
October 23, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided by an 
out-of-network provider from September 1, 2022, to September 3, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you would like the 
copayment to be lower. 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 30% 
coinsurance for each out-of-network Medicare-covered hospital stay for unlimited days each time you are 
admitted. 
 
 You have been asked to pay a $2776.96 coinsurance for the inpatient hospital stay ($9256.53 allowed amount x 
.30 = $2776.96 rounded up). This item/service falls within the inpatient hospital care benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the inpatient hospital stay provided by an out-of-network 
provider from September 1, 2022, to September 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on March 14, 2023. 
 
You asked the Plan to waive the copayment for office visit. You say that you would like the $35 copay 
forgiven because all the doctor did was look at your hand and you were out the door. 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 physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $35 copayment for 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 waive the copayment for office visit provided on March 14, 2023.