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

 
We decided that the Plan does not have to pay for procedure code 22853 rendered on February 10, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the 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 22853 is "Insertion of interbody biomechanical device(s) 
(eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), 
when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List 
separately in addition to code for primary procedure)." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that the operative report does not 
include documentation of insertion of anterior biomechanical device with plate or screw fixation. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 22853 rendered on February 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Coflex Interlaminar Stabilization device. 
 
You asked the Plan to pre-approve the Coflex procedure. You say that this procedure is necessary due to the 
failure of conservative treatments. You are in severe pain and require this procedure to regain the ability to do 
everyday activities. The Plan denied your request. The Plan says the request is not medically necessary the 
enrollee is not enrolled in a Medicare approved study which is looking at the benefits of the Coflex device. 
 
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 the Coflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Coflex Interlaminar Stabilization device is considered 
experimental/investigational and is not medically necessary for the treatment of chronic back pain.  
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 Coflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Coflex Interlaminar Stabilization device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81456). 
 
You asked the Plan to pre-approve the genetic testing. You say that this service is medically necessary. 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 if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the 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. The request is for genetic testing that is included in another test that 
was already performed. Additionally, the Tempus xR test is not listed as an approved test per the FDA List of 
Cleared or Approved Companion Diagnostic Devices. Therefore, we decided that the Plan does not have to 
pre-approve genetic testing (81456).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for contact lenses (V2797) provided on July 14, 2023. 
 
You asked the Plan to pay for contact lenses (V2797). You say that you did the same procedure last year and it 
was approved. The Plan denied your request. The Plan says this service is not covered under your contract 
under any normal circumstances. The Plan also says this is not covered by Medicare. 
 
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 does not cover these services under your benefit Plan. 
 
We looked at the file and the Plan's rules. The Plan rules say that Medicare covers one pair of eyeglasses or 
contact lenses after each cataract surgery that includes insertion of an intraocular lens (additional pairs of 
eyeglasses or contacts are not covered by Medicare). The record shows that you did not obtain these contacts 
after a cataract surgery. The record also shows that the requested service is excluded under the Plan benefits.  
Based on this information, we decided that the Plan's rules for coverage of contact lenses (V2797) have not 
been met. Therefore, we decided that the Plan does not have to pay for contact lenses (V2797) provided on July 
14, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for imaging services with provider provided 
from July 7, 2023, to July 9, 2023. 
 
You asked the Plan to waive the copayment for imaging services with provider. You say that you were 
admitted to the hospital through the emergency room, after discovering numerous health issues. You are 
dissatisfied with this service and feel you are being charged unfairly. 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 and a $30 copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 You have been asked to pay a $280 total copayment for imaging services with provider ($250 + $30 = $280). 
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. Therefore, we 
decided that the Plan does not have to waive the copayment for imaging services with provider provided from 
July 7, 2023, to July 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete denture repair (D5512) provided on September 1, 
2023. 
 
You asked the Plan to pay for a complete denture repair. You say that this should be covered. The Plan denied 
your request. The Plan says there is no coverage for services rendered by a denturist. 
 
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, dental services performed by someone 
other than a dentist are not covered under this benefit. Therefore, we decided that the Plan does not have to pay 
for a complete denture repair (D5512) provided on September 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam CT (D0364) provided on May 9, 2023. 
 
You asked the Plan to pay for cone beam CT. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for cone 
beam CT (D0364) provided on May 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on August 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that this was medically necessary. The Plan denied 
your request. The Plan says the dental services were received from an out-of-network provider and are not 
covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided on August 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for comprehensive oral evaluation (D0150) and 
prophylaxis (D1110) provided on August 15, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were not informed of the providers 
current network status prior to the appointment. The Plan denied your request. The Plan says you are 
responsible for any charged amount above the Plans cost-sharing amount when your services are received 
from an out-of-network provider.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for comprehensive oral evaluation (D0150) and 
prophylaxis (D1110) provided on August 15, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ferric carboxymaltose injection (J1439), normal saline 
solution infusion (J7050), intravenous infusion (96365), and intravenous infusion of hydration (96361) 
provided on December 8, 2022, to December 28, 2022, by an out-of-network (OON) provider.  
 
  You asked the Plan to pay for ferric carboxymaltose injection, normal saline solution infusion, intravenous 
infusion, and intravenous infusion of hydration. You say that the claim should be reprocessed for payment as 
the services provided were medically necessary. The Plan denied your request. The Plan says the service was 
not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the ferric carboxymaltose injection (J1439), 
normal saline solution infusion (J7050), intravenous infusion (96365), and intravenous infusion of hydration 
(96361) provided on December 8, 2022, to December 28, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), 
extraction, erupted tooth or exposed root (D7140), and intraoral - periapical first radiographic image (D0220) 
provided on July 25, 2023 
 
You asked the Plan to pay for the dental services. You say that the enrollee was seen in the office for a broken 
tooth. You also say that x-rays were taken and found that #18 and #19 needed to be extracted. The Plan denied 
your request. The Plan says coverage for these services under the member's Basic Medicare Benefit is not 
allowed, as it is excluded by statute, unless it meets specific Medicare dental coverage exception. The Plan also 
says that the enrollee does not have supplemental dental coverage. 
 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 
the enrollees teeth or the structures directly supporting the enrollees 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 limited 
oral evaluation - problem focused (D0140), extraction, erupted tooth or exposed root (D7140), and intraoral - 
periapical first radiographic image (D0220) provided on July 25, 2023
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary partial denture - flexible base (D5225) 
provided on September 7, 2023. 
 
You asked the Plan to pay for the dental service. You say that payment for your top permanent partial was 
denied because your former dentist was paid for a temporary partial that you are unable to use. You also say 
that you are not able to chew your food properly which is causing you to experience weakness. The Plan denied 
your request. The Plan says your benefit for the maxillary partial denture 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. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested service was exhausted on date of service July 14, 2022. Therefore, we 
decided that the Plan does not have to pay for the maxillary partial denture - flexible base (D5225) provided on 
September 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3. 
 
You asked the Plan to pre-approve the CGM. You say that you would like a Freestyle Libre 3 to manage your 
diabetes and because it is smaller, discreet, and more accurate. The Plan denied your request. The Plan says the 
denial of authorization is correct, because you were provided with a CGM in May of 2023. 
 
The Plan must follow Medicare rules. 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 item being requested shows to be for replacement of an identical or nearly identical item, due to wear. The 
case file shows that the existing equipment is less than 5 years old. This means that replacement of this 
equipment due to wear is not covered at this time. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 3.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on  
May 25, 2023. 
 
You asked the Plan to pay for the ED services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment. Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on May 25, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on  
May 28, 2023. 
 
You asked the Plan to pay for the ED services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment. Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on May 28, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services provided on January 19, 
2023. 
 You asked the Plan to pay for paramedic intercept services. You say that you would like reconsideration 
because the requested paramedic intercept is medically necessary. The Plan denied your request. The Plan says 
this item is not a covered benefit. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept services provided on January 19, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99285) provided 
on July 12, 2023. 
 
You asked the Plan to pay for an emergency department visit (procedure 99285). You say that procedure code 
99285 is appropriate based on the services performed. The Plan denied your request. The Plan says the records 
do not support the services at issue in this case. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 an emergency department visit (procedure 99285). Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer 
found the documentation provided supports an appropriate exam but does not support an appropriate history or 
high-level 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 an emergency department visit (procedure 99285) have not been met. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit (procedure 99285) 
provided on July 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6441, 
A6442, A6443, A6445, A6448, A6449, and A6450. 
 
You asked the Plan to pre-approve the compression stockings. You say that the requested compression wraps 
are medically necessary to treat your lymphedema. The Plan denied your request. The Plan says the requested 
surgical dressing are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6441, 
A6442, A6443, A6445, A6448, A6449, and A6450 are covered only when they are used to treat an open 
venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are 
covered only when they are used as dressings over a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6441, A6442, A6443, A6445, A6448, A6449, and A6450.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on February 21, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the physician services provided on February 21, 
2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81232, 81306, 81231, and 81335) provided on 
June 6, 2023. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (81232, 81306, 81231, and 81335) provided on June 6, 2023.