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

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) and supplies provide 
don June 28, 2023. 
 
You asked the Plan to pay for the CGM and supplies. 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 physician order for the supplies provided in this case. The treating provider confirmed that an order for the billed items was not sent to the rendering provider in this case. Therefore, we 
decided that the Plan does not have to pay for the continuous glucose monitor (CGM) and supplies provide don 
June 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided May 17, 
2023, to June 8, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you are requesting 
reconsideration based on medical necessity and evidence based medical literature that substantiate the efficacy 
of the treatment rendered. The Plan denied your request. The Plan says a PCD coded as E0675 is not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided May 17, 2023, to June 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight testing rendered on June 4, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that pharmacogenomics testing is covered when 
specific criteria are met. 
 
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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found there is no documentation of the drugs 
being requested for augmentation or starting/switching to in the submitted records. There is no documentation 
that the provider had already considered non-genetic factors to make a preliminary drug selection. The criteria for coverage are not met and the testing was not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the GeneSight testing rendered on June 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a mastectomy bra, and breast prosthesis 
provided on July 08, 2023. 
 
You asked the Plan to waive the coinsurance for a mastectomy bra, and breast prosthesis. You say that you 
were told that there would be no charge. 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 prosthetic devices and medical supplies. 
 
You have been asked to pay 20% coinsurance for a mastectomy bra, and breast prosthesis. This item/service 
falls within the prosthetic devices and medical 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 you owe is $156.68 ($783.42 allowed amount x 
20% = $156.68). Therefore, we decided that the Plan does not have to waive the coinsurance for a mastectomy 
bra, and breast prosthesis provided on July 08, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
August 29, 2023. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you left because 
you could not sit there any longer without being seen for five hours. 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 $110 
copayment for emergency care. 
 
You have been asked to pay a $110 copayment for the emergency room services. This item/service falls within 
the emergency 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 emergency room 
services provided on August 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental service (D5862) provided on March 7, 2023. 
 
You asked the Plan to pay for the dental service. You say that you had all upper teeth removed and the lower 
teeth were protected with a guard during radiation treatments. You also say that in 2021, you broke off the top 
of a tooth and learned the rest of your teeth had been damaged from radiation. The Plan denied your request. 
The Plan says dental services billed with codes D0120 through D9999 are not covered under medical plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the dental service (D5862) 
provided on March 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on October 17, 2023, billed 
with codes 87500, 87563, 87591, 87481, 87651, 87653, 87641, 87798, G0452, 87491, 87496, 87529 and 
87532. 
 
You asked the Plan to pay for laboratory services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says panel testing should be billed using one Current Procedural 
Terminology (CPT) code on the claim. 
 
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 laboratory services provided on October 17, 2023, billed with codes 87500, 
87563, 87591, 87481, 87651, 87653, 87641, 87798, G0452, 87491, 87496, 87529 and 87532.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies (A4239) provided on July 21, 2023. 
 
You asked the Plan to pay for the diabetic supplies. You say that these items were medically necessary. 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 relevant medical records which support medical necessity for the supplies provided 
in this case. The records do not mention the need for the billed items. 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 (A4239) provided on July 21, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an abdomen and pelvis computed 
tomography (CT) scan provided on August 30, 2023. 
 
You asked the Plan to waive the copayment for an abdomen and pelvis computed tomography (CT) scan. You 
say that you think that the copayment is too high. 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 $250 
copayment for other Medicare-covered diagnostic radiology services, including CT scans. 
 
You have been asked to pay a $250 copayment for an abdomen and pelvis computed tomography (CT) scan. This item/service falls within the other Medicare-covered diagnostic radiology services, including CT scans 
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. 
However, since the allowed amount is less than the standard copayment, you only owe $200.94. Therefore, we 
decided that the Plan does not have to waive the copayment for an abdomen and pelvis computed tomography 
(CT) scan provided on August 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 3, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing was not billed correctly. 
 
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 laboratory services rendered on August 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the peripheral nerve block injection described by code 
64415. 
 
You asked the Plan to pay for 64415. You say that 64415 should be paid as billed because it was requested by 
the surgeon and was billed with modifier -XE. The Plan denied your request. The Plan says 64415 is denied 
because it is included in payment for procedure code 01810. 
 
The Plan must follow Medicare rules. Medicare rules say that a peripheral nerve block may be separately 
reported on the same day as an anesthesia code 0XXXX if the mode of intraoperative anesthesia is general, the 
adequacy of the intraoperative anesthesia is not dependent on the nerve block, it is administered for 
postoperative pain management at the request of the surgeon, and modifier -59 or -XU is appended. 
 
We looked at the file and Medicare rules. In this case we confirmed that 64415 was billed on the same date as 
anesthesia code 01810. Records indicate the enrollee had right hand surgery and the primary anesthesia 
technique was general. Per Medicare rules, if a peripheral nerve block injection is administered for 
postoperative pain management on the same day as an anesthesia code such as 01810, modifier -59 or -XU 
should be appended to indicate this. We confirmed that in this case, 64415 was billed with modifier -XE, rather 
than -59 or -XU, as required. Based on this information, we decided that Medicare rules for coverage of 64415 
have not been met. Therefore, we decided that the Plan does not have to pay for the peripheral nerve block 
injection described by code 64415.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block injection. 
 
You asked the Plan to pre-approve a genicular nerve block injection. You say that the requested procedure is 
medically necessary to treat your pain. The Plan denied your request. The Plan says the requested injection 
does not meet the requirements for approval. 
 
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 genicular nerve block injection. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested procedure is the subject of ongoing clinical trials and is 
considered experimental/investigational therapy. Therefore, the request is deemed not medically reasonable and 
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 a genicular nerve block injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a genicular nerve block injection.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on September 29, 
2023. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that this service should 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 $150 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $150 copayment for an ultrasound. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, since the allowed amount is less than the standard 
copayment, you only owe $133.31. Therefore, we decided that the Plan does not have to waive the copayment 
for an ultrasound provided on September 29, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided on September 5, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment. You say that the security guard at your 
apartment complex called the ambulance for you. The Plan denied your request. The Plan says ambulance 
services are not covered when there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 5, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport (A0998) provided on September 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 44120, 49320, and 38747, billed for date of 
service April 18, 2023. 
 You asked the Plan to pay for procedure codes 44120, 49320, and 38747. The Plan denied your request. The 
Plan says payment for codes 44120, 49320, and 38747, is bundled into payment for code 48150. 
 
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 
44120, 49320, and 38747, are column II codes to column I code 48150. 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 44120, 49320, and 38747, 
billed for date of service April 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88189 billed for April 26, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on May 31, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure code 88189 billed for April 26, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the supplies (A4239) provided on September 19, 2023. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says that only one unit is 
allowed per 30 days, and this is the second billing within a 30-day period. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that only one unit is allowed per 30 days, and this is the second 
billing within a 30-day period. Per LCD L33822, code A4239 can be billed a maximum of 3 times per 90 days. 
The Plan has not provided documentation showing that more than 3 units of code A4239 were billed in a 90-
day period. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we 
decided that the Plan has to pay for the supplies (A4239) provided on September 19, 2023.  
 
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 pay for the pneumatic compression device and appliance provided 
on August 15, 2023. 
 
You asked the Plan to pay for the pneumatic compression device and appliance. The Plan denied your request. 
The Plan says this is not covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device and appliance provided on August 15, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on July 
23, 2023. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you want to appeal the 
amount being charged. 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 $300 
copayment for ambulance services. 
 
You have been asked to pay a $300 copayment for the ambulance services. This item/service falls within the 
ambulance services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance 
services provided on July 23, 2023.