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

 
We decided that the Plan does not have to pay for procedure codes 93303, 93320, and 93325 rendered on 
February 22, 2022. 
 
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 denied codes remain not supported. 
 
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 93303: 
 
Transthoracic echocardiography for congenital cardiac anomalies; complete 
 CPT 93320: 
 
Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in 
addition to codes for echocardiographic imaging); complete 
 
CPT 93325: 
 
Doppler echocardiography color flow velocity mapping (List separately in addition to codes for 
echocardiography) 
 
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 at issue is the accuracy of the 
echocardiography coding based on the medical records provided. These records do not support the performance 
of 93303 (TTE for congenital cardiac anomalies; complete), or 93320/93325 (Doppler echocardiography. In 
summary, there is no supportive evidence that these codes were rendered in this enrollees clinical 
management. 
 
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 codes 93303, 93320, and 93325 rendered on February 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide.  
 
You asked the Plan to pre-approve a stair glide. You say that the item is medically necessary. The Plan denied 
your request. The Plan says this item is not primarily medical in nature. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a heavy-duty walker provided on April 8, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for heavy duty walker. You say that this was medically necessary. The Plan denied 
your request. The Plan says this provider is out-of-network with the Plan and 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 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 a heavy-duty walker provided on April 8, 2023, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on March 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the dental services were received from an out-of-network provider and are 
not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided on March 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the CGM and supplies provided on 
February 28, 2023, and March 30, 2023. 
 
You asked the Plan to waive the coinsurance for the CGM and supplies. You say that you were told by the 
provider that you would have no out-of-pocket cost for the items you received. 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 50% 
out-of-network coinsurance for each Medicare-covered continuous glucose monitor and supplies in accordance 
with Medicare guidelines.   
 
You have been asked to pay a total of $271.26 for the CGM and supplies. 
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
February 28, 2023 CGM $150 50% $75 
February 28, 2023 Supplies $137.50 50% $68.75 
March 30, 2023 Supplies $255.01 50% $127.51 
TOTAL:    $271.26 
 
These items fall within the diabetes self-management training, diabetic 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 coinsurance for the CGM, and supplies provided on February 28, 2023, and 
March 30, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiogram (TTE). 
 
You asked the Plan to pre-approve a TTE. You say that you would like this request to be reconsidered. The 
Plan denied your request. The Plan says this request is not medically necessary per Medicare rules as it is being 
used as screening without signs or symptoms of cardiac disease. 
 
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 a TTE. Our reviewer says that the 
requested TTE is not considered medically reasonable and necessary in this case. Our physician reviewer found 
the records show that the member had no cardiac symptoms and was medically stable from a cardiac 
standpoint. There were no new electrocardiogram changes. Our reviewer also found that there was no specific 
clinical rationale for the requested transthoracic echocardiogram.  
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 TTE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a transthoracic echocardiogram (TTE).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 30140 and 30468 billed for date of service 
November 17, 2022.  
 You asked the Plan to pay for procedure codes 30140 and 30468. You say that medical records were provided. 
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT codes 30140 and 30468 is 1. The MAI value for this code is 2. You billed 2 
units for each code, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
30140 and 30468 billed for date of service November 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intradialytic parenteral nutrition (IDPN) (B4185, 
B4189, B4193, B4197 and B4199).  
 
You asked the Plan to pre-approve Intradialytic parenteral nutrition. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that for parenteral nutrition to be considered reasonable 
and necessary, the treating practitioner must document that enteral nutrition has been considered and ruled out, 
tried and been found ineffective, or that EN exacerbates gastrointestinal tract dysfunction. The beneficiary must 
have (a) a condition involving the small intestine and/or its exocrine glands which significantly impairs the 
absorption of nutrients or (b) disease of the stomach and/or intestine which is a motility disorder and impairs 
the ability of nutrients to be transported through and absorbed by the gastrointestinal (GI) system. The 
beneficiary must have a permanent impairment. 
 
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 Intradialytic parenteral nutrition. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has stable 
albumin and no evidence of a gastrointestinal tract disorder. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intradialytic parenteral nutrition have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Intradialytic parenteral nutrition (IDPN) (B4185, B4189, B4193, B4197 
and B4199).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment (D6057) and an abutment 
supported crown (D6059) provided on May 24, 2023. 
 
You asked the Plan to pay for D6057 and D6059. You say that this dental work was medically necessary. The 
Plan denied your request. The Plan says the rendered dental services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
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 pay for a custom 
fabricated abutment (D6057) and an abutment supported crown (D6059) provided on May 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenetic testing billed for date of service April 
14, 2023. 
 
You asked the Plan to pay for the billed services. You say that the codes are allowable and payable. The Plan 
denied your request. The Plan says the test specific identifier was not 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. 
 
We looked at the file and Medicare rules. A 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 have not been 
met. Therefore, we decided that the Plan does not have to pay for the pharmacogenetic testing billed for date of 
service April 14, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided on March 
24, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for SNF. You say that the records provided support these services. The Plan denied 
your request. The Plan says these services can be provided in-network. 
 
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 skilled nursing facility (SNF) services provided on 
March 24, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on May 11, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99202) provided on May 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid examination and selection; binaural (92591) 
provided on June 14, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not payable as it was rendered 
by an out-of-network provider.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.   
  
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of this service have not been met. Specifically, the Plans contract states that one non-Medicare-
covered hearing aid exam is covered per year only when rendered by the Plans select hearing aid provider. 
However, the hearing aid exam in this case was rendered by an out-of-network provider. Therefore, we decided 
that the Plan does not have to pay for the hearing aid examination and selection; binaural (92591) provided on 
June 14, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on 
December 12, 2022. 
 
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 documents do not support this level of care. 
 
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 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 documentation supports a 
comprehensive exam, but not a comprehensive history or medical decision making of high complexity. 
 
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 initial hospital care (procedure code 99223) rendered on December 12, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve an amnio graft placement of right eye. 
 
You asked the Plan to pre-approve an amnio graft placement of right eye. You say that the enrollee needs this 
due to pain in the right eye. The Plan denied your request. The Plan says that there is no indication of trauma, 
and though there is corneal erosion, there is no lesion and since it was caused from long 
standing entropion. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 an amnio graft placement of right eye. 
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has chronic entropion of right lower eyelid that has caused a 
recurrent corneal erosion documented on eye exam. The enrollee has tried conservative treatment including tear 
drops, gels, and ointments has been used without success. Surgery is planned to repair the entropion, but the 
corneal erosion needs to be treated. This condition does meet medical necessity for amniotic membrane graft 
placement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an amnio graft placement of right eye have been met. Therefore, we decided 
that the Plan has to pre-approve an amnio graft placement of right eye.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit, and related services provided on April 13, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visit, and related services. You say that this is supported in the records. 
The Plan denied your request. The Plan says enrollees must receive their care from a network provider. 
 
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 
items/services 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 related services provided on 
April 13, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214-25 billed for date of service March 29, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the medical records support the services. The 
Plan denied your request. The Plan says the code is included in the global period for code 31615. 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 code 99214, billed with modifier -25 is not supported in the medical record. Specifically, the 
medical records do not show the evaluation and management service was significantly identifiable from the 
minor procedure performed on the date of service at issue. Based on this information, we decided that Medicare 
rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code 99214-25 billed for date of service March 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for prophylaxis (D1110) and a periodic oral evaluation 
(D0120) provided on May 9, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you would like reimbursement for this 
cleaning. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network provider.  
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for prophylaxis (D1110) and a periodic oral 
evaluation (D0120) provided on May 9, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Jemperli. 
 
You asked the Plan to pre-approve Jemperli. You say that the requested drug will assist the enrollee to achieve 
or maintain maximum functional capacity in performing daily activities. The Plan denied your request. The 
Plan says review of the information provided does not show documentation that the enrollee has a defective 
gene mismatch repair (dMMR) or high microsatellite instability (MSI-H). 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Jemperli. Our reviewer says that the 
requested drug is not reasonable or medically necessary. Our physician reviewer found that Jemperil is not FDA approved for colon cancer and tumors not deficient in MMR. Use is not supported by one of the major 
drug compendia or by clinical research that appears in a CMS-approved medical journal.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Jemperli have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Jemperli.