Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on August 18, 2023, billed 
with codes 87150, 87481, 87641, 87653, 87798 and 87801. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that a laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was a laboratory panel that was not billed with a single panel 
code as required. Based on this information, we decided that Medicare rules for coverage of the laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on August 18, 2023, billed with codes 87150, 87481, 87641, 87653, 87798 and 87801.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit (AWV) provided on July 3, 2023. 
 
You asked the Plan to pay for the annual wellness visit (AWV). You say that these checkups have saved your 
Plan a lot of money and problems in the past. You also say that you feel this should be covered. The Plan 
denied your request. The Plan says the benefit for this service has been exhausted. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for the annual wellness visit (AWV) provided on July 
3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy (90837) provided on June 20, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that the service should be covered. The Plan denied 
your request. The Plan says the rendering providers specialties are Master of Social Work, Licensed 
Professional Counselor, and National Certified Counselor, all of which are on the list of individuals who are 
not eligible to enroll 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 psychotherapy (90837) provided on 
June 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an AccuTrack motor technology (K0108). 
 
You asked the Plan to pre-approve an AccuTrack motor technology. You say that the AccuTrack motor 
technology is not an integral part of the base, thus a split decision should be possible. The Plan denied your 
request. The Plan says the AccuTrack motor upgrade exceeds the enrollee's need and cannot be approved. 
 
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 an AccuTrack motor technology. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested accessory is not medically necessary to meet the enrollee's 
needs. Our reviewer also found that the enrollee is able to drive a power wheelchair with a head array system. 
 
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 AccuTrack motor technology have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an AccuTrack motor technology (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional acupuncture visits. 
 
You asked the Plan to pre-approve additional acupuncture services. You say that the requested services are a 
necessity for your care. The Plan denied your request. The Plan says rules for coverage for acupuncture have 
not been met. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.   
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, there is no evidence in the case record that the 
acupuncturist at issue in this case is under the appropriate level of supervision of a physician, physician 
assistant, or nurse practitioner/clinical nurse specialist. Therefore, we decided that the Plan does not have to 
pre-approve additional acupuncture visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service March 7, 2023. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the billed services cannot be verified.  
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. The enrollees information on the claim is inconsistent with the 
information in the records. Based on this information, we decided that the Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for the lab testing billed for date of service 
March 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis with sleeve provided on June 21, 2023. 
 
You asked the Plan to pay for knee orthosis with sleeve. You say that you are appealing with supporting 
records. 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. Specifically, the proof of delivery does not include 
specification of the items delivered nor does it include a signature from the enrollee or another valid party validating successful delivery of the specific items billed on this claim. Therefore, we decided that the Plan 
does not have to pay for a knee orthosis with sleeve provided on June 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on August 
30, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. 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 $45 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 a specialist office visit provided on August 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve blocks. 
 
You asked the Plan to pre-approve genicular nerve blocks. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says this procedure is experimental/investigational. 
 
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 genicular nerve blocks. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is considered experimental/investigational and is the subject of 
ongoing clinical trials. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve blocks have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve blocks.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 21, 2022. 
 
You asked the Plan to pay for laboratory services. 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 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 laboratory services 
provided on December 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutments-includes placement for 
teeth number 5 and 6 (D6057 x 2) and abutment supported porcelain/ceramic crowns for teeth number 5 and 6 
(D6058 x 2).  
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested dental items are not covered under the 
supplemental dental policy.  
 
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 are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve custom 
fabricated abutments-includes placement for teeth number 5 and 6 (D6057 x 2) and abutment supported 
porcelain/ceramic crowns (D6058 x 2).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on March 10, 2023. 
 
You asked the Plan to pay for psychotherapy services. You say that this provider is in-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 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 psychotherapy services 
provided on March 10, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from July 16, 2023, to July 
31, 2023. 
 
You asked the Plan to pay for the home health services. You say that you believe this claim should be paid as 
in-network. The Plan denied your request. The Plan says you billed this claim with an incorrect Type of Bill 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that valid home health claims must be billed with one 
of the following Type of Bill codes: 0327, 0328, or 0329. 
 
In this case, you billed the services in dispute with Type of Bill code 0322, which is not valid.  Final home 
health claims must be billed with Type of Bill code 0329.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to 
pay for home health services provided from July 16, 2023, to July 31, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an LTACH admission. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are necessary. The Plan 
denied your request. The Plan says the criteria for an LTACH admission has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee needs repeated imaging in one or two weeks for concerns related to a 
developing liver abscess. The enrollee has not had a return of bowel function and is requiring the 
commencement of trickled tube feeds. No permanent feeding access is in place. The enrollees acute 
hospitalization has not finished and is not appropriate for an LTACH transfer. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an LTACH admission.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OneTouch Ultra test strips (A4253). 
 
You asked the Plan to pre-approve OneTouch Ultra test strips. The Plan denied your request. The Plan says 
only the preferred brand products listed in the EOC are covered.  
 The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for OneTouch Ultra test strips. Therefore, we decided that the Plan does not have to pre-approve OneTouch 
Ultra test strips (A4253).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an elbow orthosis provided on July 5, 2023. 
 
You asked the Plan to pay for elbow orthosis. You say that you are appealing with supporting records. 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. Specifically, the shipping receipt does not include 
specification of the item delivered and the packing slip which specifies the items included for shipment does 
not include an identifier  such as the carriers tracking number  to associate it with the delivery made. 
Therefore, we decided that the Plan does not have to pay for an elbow orthosis provided on July 5, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3 (J7328). 
 You asked the Plan to pre-approve Gelsyn-3. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested viscosupplement device. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Gelsyn-3. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of Orthovisc or 
Supartz FX before they will approve the requested drug. In this case, the enrollee has not tried and failed the 
required drug(s). Our reviewer found that there is no documentation provided indicating that the Plan's required 
drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3 (J7328).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided on February 9, 2023. 
 
You asked the Plan to pay for the outpatient service. You say that your primary doctor will not do a referral. 
You also say that you did not know this provider was not in-network. The Plan denied your request. The Plan 
says the primary evidence of benefits (EOB) has not been received. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has direct the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the outpatient service until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for the office visit (99213) provided on February 9, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 88108-26 billed for May 24, 2023. 
 
You asked the Plan to pay for the billed services. You say that the documents support the billed procedure. The 
Plan denied your request. The Plan says that 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. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. Code 88108-26-59 was paid for by the Plan on July 7, 
2023. However, code 88108-26 was denied as a duplicate. The medical records show that two separate 
pathology smears were collected and reviewed. Based on this information, we decided that Medicare rules for 
coverage of the billed services have been met. Therefore, we decided that the Plan has to pay for procedure 
code 88108-26 billed for May 24, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (G0483, 80053, 80061, 83036 and 
85025) provided on June 16, 2023. 
 
You asked the Plan to pay for laboratory services. You say that these services were reported appropriately and 
should be paid. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be 
reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that R73.9 has an Excludes1 note in relation to E11.42. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for laboratory services have not been met. Therefore, we decided that the Plan does not have to 
pay for laboratory services (G0483, 80053, 80061, 83036 and 85025) provided on June 16, 2023.