Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on August 10, 2023. 
 
You asked the Plan to pay for diabetic supplies. You say that you have provided all of the appropriate 
documents needed for payment. The Plan denied your request. The Plan says the documentation requirements 
have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. The proof of delivery provided does not have the 
enrollees signature. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for diabetic supplies 
provided on August 10, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health provided on July 01, 2023. 
 
You asked the Plan to pay for the outpatient mental health. You say that the services were medically necessary. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The Plan had network providers available who were capable of providing the items/services at issue in this appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that 
would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to 
pay for the outpatient mental health provided on July 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99310-25 provided June 28, 2023. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the medical records submitted do not support high level of medical decision making or total time 
required of the code billed; therefore, the validity and accuracy of the claim cannot be verified. 
 
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 99310 is subsequent nursing facility care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A comprehensive 
interval history; A comprehensive examination; Medical decision making of high complexity. Counseling 
and/or coordination of care with other physicians, other qualified health care professionals, or agencies are 
provided consistent with the nature of the problem(s) and the patient's and/or family's needs. The patient may 
be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 35 minutes are spent at the bedside and on the patient's facility floor or unit. 
 
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 service. Our reviewer found the encounter note from this 
date describes the enrollee as presenting for evaluation of a right hip surgical site and sacral pressure ulcer. 
Wound care including debridement was provided. Vitals were stable. However, the sacral wound was infected 
and necrotic. He was recommended hospice care for comfort care. The documentation for this encounter does 
not include a comprehensive history or physical and does not support a high level of medical decision-making.  
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99310-25 provided June 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on July 14, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the tests should not be 
billed separately. 
 
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 the lab panel provided on July 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy (EGD) 
with biopsy provided on August 24, 2023. 
 
You asked the Plan to waive the copayment for an esophagogastroduodenoscopy (EGD) with biopsy. You say 
that you were told that this service would be fully 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 a $290 
copayment for in-network Medicare-covered surgery or other services provided at an outpatient hospital. 
 
You have been asked to pay a $290 copayment for an esophagogastroduodenoscopy (EGD) with biopsy. This item/service falls within the in-network Medicare-covered surgery or other services provided at an outpatient 
hospital 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 an 
esophagogastroduodenoscopy (EGD) with biopsy provided on August 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis services to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve dialysis services. You say that the OON provider at issue is a necessity for 
the enrollee's care. The Plan denied your request. The Plan says rules for coverage for OON services have not 
been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The Plan has network providers available who are capable of providing the items/services at issue in this appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) We found no exception that would require the Plan to pre-approve these items/services. 
Therefore, we decided that the Plan does not have to pre-approve dialysis services to be provided by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre.  
You asked the Plan to pre-approve a FreeStyle Libre. 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. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that you have not had an in-person visit 
with their treating physician to evaluate their diabetes control and to determine whether the criteria for 
coverage have been met. Based on this information, we decided that Medicare rules for coverage of a FreeStyle 
Libre have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a glucose monitor (A9277, A9276) provided on October 6, 
2023. 
 
You asked the Plan to pay for the glucose monitor. You say that this item was medically necessary. The Plan 
denied your request. The Plan says this item is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that products reviewed by the Pricing, Data Analysis 
and Coding (PDAC) contractor which do not meet the DME benefit category requirements must be coded as 
A9276, A9277, A9278, or A9279 and will be denied as non-covered. 
 
We looked at the file and Medicare rules. The type of glucose monitor billed is not covered under Medicare 
rules. Based on this information, we decided that Medicare rules for coverage of the glucose monitor have not 
been met. Therefore, we decided that the Plan does not have to pay for a glucose monitor (A9277, A9276) 
provided on October 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 30, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that 
would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to 
pay for an office visit provided on August 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on August 14, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the panel should be 
reported with one code. 
 
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 the lab panel provided on August 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a manual wheelchair provided on April 21, 2023. 
 
You asked the Plan to pay for a manual wheelchair. You say that you need this item in order to be able to 
ambulate. You did not know this provider was out-of-network. The Plan denied your request. The Plan says 
that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to 
pay for a manual wheelchair provided on April 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service December 2, 
2022. 
 
You asked the Plan to pay for procedure code 99497. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 99497 is bundled into payment for code 99223. 
 
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 99497 
is a column II code to column I code 99223. 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 99497 billed for date of service December 2, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for progressive lenses (V2781) provided on June 13, 2023. 
 
You asked the Plan to pay for progressive lenses. You say that you are being charged for lenses. You also say 
that the Plan provides a generous amount for frames, but without the lenses there is no point to having frames. 
The Plan denied your request. The Plan says this service is not covered under your contract under any normal 
circumstances. 
 
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 standard lenses. 
 
We looked at the file and the Plan's rules. The Plan rules say options that are not covered include (but are not 
limited to) progressive lenses. Based on this information, we decided that the Plan's rules for coverage of 
progressive lenses have not been met. Therefore, we decided that the Plan does not have to pay for progressive 
lenses (V2781) provided on June 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the brace provided on August 16, 2023. 
 
You asked the Plan to waive the coinsurance for the brace. You say that you were unaware of the coinsurance. 
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 20% 
coinsurance for durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the brace. This item/service falls within the durable medical 
equipment and related supplies benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. The total amount you owe is $337.56 ($1,687.79 allowed amount x 20% = $337.56). Therefore, we decided that the Plan does not have to waive the coinsurance for the brace provided on 
August 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight portable power wheelchair (K0012). 
 
You asked the Plan to pre-approve a lightweight portable power wheelchair. You say that your current power 
chair is not usable and is too big to transfer to and from your car or have in your home. You require a power 
chair that is lightweight and foldable that can fit in a car. The Plan denied your request. The Plan says the 
requested lightweight folding electric wheelchair is not medically necessary under Medicare.  
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. Medicare rules say that, in no case can the RUL of equipment be less than 5 years. 
The rules also say that replacement due to wear is not covered during the RUL of the equipment.  
 
The file shows that you have a Group 2 power wheelchair (K0823) which was approved December 19, 2022. 
The Group 2 power wheelchair serves the same purpose as the lightweight portable power wheelchair. 
Therefore, we decided that the Plan does not have to pre-approve a lightweight portable power wheelchair 
(K0012).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640-59 provided August 22, 2023. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered 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. 
 
In this case, we have confirmed that code 87640 is a column II code to column I code 87641; however, 87640 
was billed with a modifier.  
 
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 service. Our reviewer found the documentation submitted 
was reviewed and does not meet criteria. The provider reported, procedure code with appended modifier 59- 
Distinct procedural service to bypass the NCCI Edit with CPT 87641. However, the medical record does not 
include documentation to support a distinct procedural service, as staphylococcus aureus is included in the 
more comprehensive procedure, which in this case is CPT 87641. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 87640-59 provided August 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic supplies provided on August 22, 2023. 
 
You asked the Plan to pay for the diabetic supplies. You say that you do not agree with the denial of payment, 
you have sent all the appropriate documents. The Plan denied your request. The Plan says you are not a Plan 
contract provider, and you are not enrolled in Medicare. Therefore, the claim was denied. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the diabetic supplies provided on August 
22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on August 25, 2023. 
 
You asked the Plan to pay for diabetic supplies. You say that you have provided all of the appropriate 
documents needed for payment. The Plan denied your request. The Plan says the documentation requirements 
have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. The proof of delivery provided does not have the 
enrollees signature. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for diabetic supplies 
provided on August 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve trigger point injections. 
 
You asked the Plan to pre-approve trigger point injections. You say that the injections requested are necessary 
to minimize your pain and stay off opioids. The Plan denied your request. The Plan says the requested 
injections are 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 trigger point injections. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support all of the LCD criteria necessary for approval. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of trigger point injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve trigger point injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) provided on August 
24, 2023. 
 
You asked the Plan to pay for the DME. The Plan denied your request. The Plan says this provider does not 
participate in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the durable medical equipment (DME) 
provided on August 24, 2023.