Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. 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 hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found inpatient stay is not needed. The surgery may be safely performed with a 
48-hour observational stay. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drugs or medicaments dispensed in the office for home use 
(D9630) provided on December 27, 2022. 
 
You asked the Plan to pay for dental services. You say that you should not have to pay the billed services, 
because you never received the services. The Plan denied your request. The Plan says this service is not 
covered under your 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. Drugs or medicaments 
dispensed in the office for home use (D9630) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D9630 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for drugs or 
medicaments dispensed in the office for home use (D9630) provided on December 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services rendered on December 29, 2021. 
 
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 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 services have not 
been met. Therefore, we decided that the Plan does not have to pay for laboratory services rendered on 
December 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 43259 billed for date of service June 2, 2022. 
 
You asked the Plan to pay for procedure code 43259. You say that this service was necessary and was reported 
correctly. The Plan denied your request. The Plan says this service is not supported in the medical record. 
 
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 43259 is esophagogastroduodenoscopy, flexible, 
transoral; with endoscopic ultrasound examination, including the esophagus, stomach, and either the duodenum 
or a surgically altered stomach where the jejunum is examined distal to the anastomosis. 

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 43259. Our reviewer says that this code is 
not supported by the medical records provided. Our reviewer found the records do not document that an 
esophagogastroduodenoscopy with an endoscopic ultrasound was performed on June 2, 2022. 
 
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 43259 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 43259 billed for date of service June 2, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for eyeglasses received on December 7, 2022. 
 
You asked the Plan to pay for the glasses. You say that this should be covered, as you no longer want the 
glasses and want to get your credit back. The Plan denied your request. The Plan says that 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 does not say in clear and accurate terms 
how much you should expect to pay for eyeglasses.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay anything 
for eyeglasses. The Plan contract does not clearly say how much enrollees must pay for the glasses. This means 
that the Plan did not follow Medicare rules for disclosure of cost sharing information. The plan must hold you 
harmless for these glasses. Therefore, we decided that the Plan has to pay for eyeglasses received on December 
7, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anti-reflective coating provided on September 9, 2022. 
 
You asked the Plan to pay for the anti-reflective coating. You say that your glasses should be covered and that 
the standard allowances should not be applied. The Plan denied your request. The Plan says the 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 does not cover the anti-reflective coating. 
 
We looked at the file and the Plan's rules. Specifically, the anti-reflective coating is not a covered benefit. 
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 provided on 
September 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient psychiatric hospitalization provided on 
December 9, 2022, through December 15, 2022. 
 
You asked the Plan to pay for the acute inpatient psychiatric hospitalization. You say that the services were 
medically necessary. The Plan denied your request. The Plan says the services were not medically necessary. 
 
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 pay for the acute inpatient psychiatric 
hospitalization. Our reviewer says that the service was not medically necessary. Our physician reviewer found 
it did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient 
level of care rather than a lower level of care beyond the dates in question as he did not have any suicidal or 
homicidal thoughts, auditory or visual hallucinations or abnormal 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 the acute inpatient psychiatric hospitalization have not been met. Therefore, we 
decided that the Plan does not have to pay for the acute inpatient psychiatric hospitalization provided on 
December 9, 2022, through December 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes G0444, 99173, and 96127 billed for date of 
service August 10, 2022. 
 
You asked the Plan to pay for procedure codes G0444, 99173, and 96127. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says payment for codes G0444, 99173, and 96127 is 
bundled into payment for other codes 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, we have confirmed that code G0444 
is a column II code to column I code 99497. This claim has not been billed with an appropriate modifier to 
bypass the edit. 
 
We have confirmed that code 99173 is a column II code to column I code 99497. This claim has not been billed 
with an appropriate modifier to bypass the edit. 
 
We have confirmed that code 96127 is a column II code to column I code G0439 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. Therefore, we decided that the Plan 
does not have to pay for procedure codes G0444, 99173, and 96127 billed for date of service August 10, 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 81407, 81408, 81479, 81210 and 81328. 
 
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 81407, 81408, 81479, 81210 and 81328.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481 and 87653 billed for date of service 
November 4, 2022. 
 
You asked the Plan to pay for procedure codes 87481 and 87653. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for codes 87481 and 87653 is bundled into 
payment for code 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 codes 
87481 and 87653 are a column II codes to column I code 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 codes 87481 and 87653 billed for 
date of service November 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue additional reimbursement in the amount of $97 for the 
incisional biopsy of the oral tissue (D7286) provided on July 29, 2022. 
 
You asked the Plan to issue additional reimbursement. You say that you are requesting a reconsideration of the 
Plan's denial for payment. 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 the Plan reimburses 
you up to $1,000 every year for non-Medicare covered preventive dental services and non-Medicare covered 
comprehensive dental services combined.  
 
You have been asked to pay $97 for the dental service provided. The Plan reimburses you up to $1,000 every 
year for preventive and comprehensive dental services. You previously received dental services in the amount 
of $447 that were paid for by the Plan. The Plan has agreed to issue payment in the amount of $553 for the 
incisional biopsy service provided as you have reached the annual maximum dental benefit of $1,000 for this 
calendar year. You will be responsible for the remaining amount of $97 as you have exceeded the dental 
benefit. 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 issue additional reimbursement in the amount of $97 for the incisional 
biopsy of the oral tissue (D7286) provided on July 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, harness, and electronic 
connection device for a power wheelchair. 
 
You asked the Plan to pre-approve expandable controller, harness, and electronic connection device. You say 
that you need assistance getting around safely. The Plan denied your request. The Plan says your upper limb 
strength and function are adequate to control the wheelchair power options using their own switches. 
 
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 expandable controller, harness, and electronic connection device. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the records indicate that you have 3 to 4 
out of 5 bilateral upper extremity strength and are independent with eating, thus indicating that you have 
adequate upper extremity strength and function to operate the wheelchair's power options with their own 
switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of expandable controller, harness, and electronic connection device have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller, harness, and 
electronic connection device for a power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate for L5-S1 transforaminal lumbar 
interbody fusion (TLIF). 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the enrollee has tried conservative 
treatment and is a reasonable candidate for surgery. The Plan denied your request. The Plan says studies have 
not proven that this is helpful for treatment of the enrollee's condition. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate is experimental, 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 bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate for L5-S1 transforaminal lumbar interbody fusion (TLIF).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection by nucleic acid (DNA or RNA) 
candida species, amplified probe technique (87481) mycobacteria tuberculosis, amplified probe technique 
(87556) infectious agent detection by nucleic acid (DNA or RNA) staphylococcus aureus, methicillin resistant, amplified probe technique) (87641) infectious agent detection by nucleic acid (DNA or RNA) not otherwise 
specified (87798) provided September 20, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that please see the attached documents 
requesting reconsideration and payment in full for the molecular PCR test performed. The Plan denied your 
request. The Plan says the charges are considered experimental or investigational and is not covered. 
 
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 laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case, there was no specific clinical rationale for the requested laboratory tests. 
The review has determined that the items/services at issue in this case were 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 the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for infectious agent detection by nucleic acid (DNA or RNA) candida species, amplified 
probe technique (87481) mycobacteria tuberculosis, amplified probe technique (87556) infectious agent 
detection by nucleic acid (DNA or RNA) staphylococcus aureus, methicillin resistant, amplified probe 
technique) (87641) infectious agent detection by nucleic acid (DNA or RNA) not otherwise specified (87798) 
provided September 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-sterile gloves. 
 
You asked the Plan to pre-approve the supplies. You say that you have been receiving incontinence supplies for 
several years. You also say that the supplies always included latex gloves. The Plan denied your request. The 
Plan says the requested supplies are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that durable medical equipment may be covered 
when certain criteria have been met.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the supplies have not been met. The requested supplies are disposable and therefore are not 
covered. Therefore, we decided that the Plan does not have to pre-approve non-sterile gloves.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. 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 hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the laminectomy surgery may be safely performed with a 48 hour 
observational stay. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.