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

 
We decided that the Plan does not have to pay for a pain management office visit provided on June 23, 2022. 
 
You asked the Plan to pay for a pain management office visit. You say that this was medically necessary and 
should be covered. 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. 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 pain management 
office visit provided on June 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medication assisted treatment visit provided on September 
26, 2022. 
 
You asked the Plan to pay for a medication assisted treatment visit. You say that this is a walk in service, there 
should not be any referrals or prior authorizations needed. 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. 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 medication assisted 
treatment visit provided on September 26, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance stabilization services 
provided on January 30, 2023. 
 
You asked the Plan to waive the copayment for the ambulance stabilization services. You say that you did not 
ask the ambulance to come. 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 $270 
copayment for in-network ambulance stabilization services. 
 
You have been asked to pay a $270 copayment for the ambulance stabilization services. This item/service falls 
within the in-network ambulance stabilization 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. The records show stabilization services were provided. 
Therefore, we decided that the Plan does not have to waive the copayment for the ambulance stabilization 
services provided on January 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the glucometer you have hurts your fingers. The 
Plan denied your request. The Plan says you do not require insulin three or more times daily. 
 
  
 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 Mis sensor. 
 
You asked the Plan to pre-approve the Dexcom G6 Mis sensor. The Plan denied your request. The Plan says 
the enrollee does not require insulin three or more times daily. 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the Dexcom G6 Mis sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Dexcom G6 Mis sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit coded 99204 for date of service November 
22, 2022. 
 
You asked the Plan to pay for the office visit. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services billed are 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 code 99204 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and 
moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is 
spent on the date of the encounter. 
 
We find that CPT code 99204 is not supported in the medical record. Specifically, the documentation does not 
include the time spent on this encounter to verify that 45-59 minutes was spent. Based on this information, we 
decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the 
Plan does not have to pay for the office visit coded 99204 for date of service November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 94660 billed for date of service July 31, 
2022. 
 
You asked the Plan to pay for procedure code 94660. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says the provided records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  

In this case, the CPT Code Manual definition of code 94660 is: Continuous positive airway pressure ventilation 
(CPAP), initiation and management. 
 
We find that CPT code 94660 is not supported. Specifically, no medical records were provided to support that 
initiation and management of a CPAP device were provided on the date of service at issue in this case. Based 
on this information, we decided that Medicare rules for coverage of procedure code 94660 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 94660 billed for date of service 
July 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve i-FACTOR Peptide Enhanced Bone Graft (20930 and 
20931). 
 
You asked the Plan to pre-approve i-FACTOR Peptide Enhanced Bone Graft (20930 and 20931). You say that 
the requested i-FACTOR Peptide Enhanced Bone Graft is medically necessary. The Plan denied your request. 
The Plan says the requested i-FACTOR Peptide Enhanced Bone Graft is 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 i-FACTOR Peptide Enhanced Bone 
Graft (20930 and 20931). Our reviewer says that the requested i-FACTOR Peptide Enhanced Bone Graft is not medically necessary. Our physician reviewer found i-FACTOR allograft is experimental in cases of spinal 
fusion. Iliac crest bone graft is the gold standard. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of i-FACTOR Peptide Enhanced Bone Graft (20930 and 20931) have not been 
met. Therefore, we decided that the Plan does not have to pre-approve i-FACTOR Peptide Enhanced Bone 
Graft (20930 and 20931).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99497-25 billed for date of service March 7, 2022. 
 
You asked the Plan to pay for code 99497-25. You say that the medical records support payment of this 
service. The Plan denied your request. The Plan says code 99497-25 is not supported by the medical records. 
 
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 99497-25 is Advance care planning including the 
explanation and discussion of advance directives such as standard forms (with completion of such forms, when 
performed), by the physician or other qualified health professional; first 30 minutes, face- to-face with the patient, family member(s) and/or surrogate). 
 
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 code 99497-25. Our reviewer says that code 99497-25 is not 
supported by the medical record. Our reviewer found based on the medical records provided there is no 
documentation of an explanation and discussion of advance directives such as standard forms (with completion 
of such forms, when performed), by the physician or other qualified health professional; first 30 minutes, face- 
to-face with the patient, family member(s) and/or surrogate for date of service March 7, 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 code 99497-25 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99497-25 billed for date of service March 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes J3420, J3411, J3415, and J1955 billed for 
October 13, 2022. 
 
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 procedure codes J3420, J3411, J3415, and J1955 are 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 code J3420 is injection, vitamin b-12 cyanocobalamin, up to 
1000 mcg. The definition of code J3411 is injection, thiamine hcl, 100 mg. The definition of code J3415 is 
injection, pyridoxine hcl, 100 mg. The definition of code J1955 is injection, levocarnitine, per 1 gm. 
 
We find that CPT codes J3420, J3411, J3415, and J1955 are not supported in the medical record. Specifically, 
the documentation shows that a pharmaceutical mix was used and the codes should be billed individually. 
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 procedure codes J3420, J3411, J3415, and J1955 
billed for October 13, 2022.
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 June 9, 2022. 
 
You asked the Plan to pay for procedure code 99497. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99497 is bundled into payment for code 99220. 
 
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 99220. 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 June 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 8, 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 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 these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
January 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic brachytherapy (0394T) and therapeutic 
radiology simulation (77280 and 77290). 
 
You asked the Plan to pre-approve electronic brachytherapy (0394T) and therapeutic radiology simulation 
(77280 and 77290). You say that the requested electronic brachytherapy (0394T) and therapeutic radiology 
simulation (77280 and 77290) are medically necessary. The Plan denied your request. The Plan says the 
requested electronic brachytherapy (0394T) and therapeutic radiology simulation (77280 and 77290) 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 electronic brachytherapy (0394T) and 
therapeutic radiology simulation (77280 and 77290). Our reviewer says that the requested electronic 
brachytherapy (0394T) and therapeutic radiology simulation (77280 and 77290) are not medically necessary. 
Our physician reviewer found radiation is a standard approach to the treatment of skin cancer and is often 
preferred over surgery when resection is likely to result in unacceptable morbidity or cosmesis. Many factors 
determine which of many treatments are best suited for an individual patient- including histology (squamous 
cell or basal cell carcinoma), size (T stage), depth, location, comorbidities. 
 
Electronic brachytherapy (EBT) devices, which are similar in that they deliver low energy radiation, are 
marketed by other manufacturers (and are Food and Drug Administration (FDA) approved). Electronic 
brachytherapy is somewhat different in that energies up to 50 kV are generated electrically via an electronic 
brachytherapy source. 
 
For this case, there are no compelling reasons offered for why superficial radiation (SRT) would be needed 
over more standard approaches of radiation delivery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of electronic brachytherapy (0394T) and therapeutic radiology simulation (77280 
and 77290) have not been met. Therefore, we decided that the Plan does not have to pre-approve electronic 
brachytherapy (0394T) and therapeutic radiology simulation (77280 and 77290).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 03, 2023. 
 
You asked the Plan to pay for lab services. You say that you cannot afford to let these claims go unpaid. 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. 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 lab services provided on 
January 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye appointment provided on October 17, 2022. 
 
You asked the Plan to pay for an eye appointment. You say that this was a follow up and should be covered. 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. 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 eye appointment 
provided on October 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on December 08, 2022. 
 
You asked the Plan to pay for nursing facility care. You say that this is supported in the records. 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. 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 nursing facility care 
provided on December 08, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination (92014) and eyeglasses (V2025, 
V2781) received on January 18, 2023, from an out-of-network provider.  
You asked the Plan to pay for a medical eye examination and eyeglasses. You say that you want the Plan to pay 
for these services. The Plan denied your request. The Plan says the vision services are only covered when you 
use an in-network provider. 
 
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 these services when you use an in-network provider. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of a medical eye examination and eyeglasses have not been met. Therefore, we decided that the Plan 
does not have to pay for a medical eye examination (92014) and eyeglasses (V2025, V2781) received on 
January 18, 2023, from an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient 
(D0150) provided on February 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were referred to a different provider and 
they had to perform the same procedure. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
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. This benefit includes the 
requested comprehensive oral evaluation - new or established patient (D0150) but is limited to One procedure 
every three plan years. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered comprehensive oral evaluation - new or established patient (D0150) on February 
15, 2022. Therefore, this benefit was exhausted as of February 23, 2022. Therefore, we decided that the Plan 
does not have to pay for comprehensive oral evaluation - new or established patient (D0150) provided on 
February 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the eye exam provided on February 9, 2023 
 
You asked the Plan to waive the deductible for the eye exam. You say that you would like this processed as in-
network. 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. Your 
contract with the Plan says that there is a $750 deductible which applies to out-of-network vision care. Your 
contract with the Plan also says you must pay a $15 copayment after meeting the deductible for out-of-network 
vision care. 
 
You have been asked to pay $95 towards the deductible. The item or service you asked the Plan to waive the 
deductible for falls within the vision care benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $750 deductible which applies to out-of-network vision care. This cost sharing is a contractual obligation that had not been met at the time the eye exam was received on February 9, 
2023. Therefore, we decided that the Plan does not have to waive the deductible for the eye exam provided on 
February 9, 2023