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

 
We decided that the Plan does not have to pay for the wound panel provided on June 28, 2023, and billed with 
codes 87481, 87640, 87651, 87653 and 87798. 
 
You asked the Plan to pay for the wound panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this test should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.   
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the wound panel provided on June 28, 2023, and billed with codes 87481, 87640, 
87651, 87653 and 87798.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Life Alert system (A9999). 
 
You asked the Plan to pre-approve a Life Alert system. You say that you are low income and have no family. 
Where you live no one can here you. With a Life button you would get help quicker. The Plan denied your 
request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Telephone alert 
systems should be denied as these are emergency communications systems and do not serve a diagnostic or therapeutic purpose. Therefore, we decided that the Plan does not have to pre-approve Life Alert system 
(A9999).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code G0416 for date of service January 31, 2023. 
 
You asked the Plan to pay for code G0416. 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 G0416 is surgical pathology, gross and microscopic 
examinations, for prostate needle biopsy, any method. 
 
We find that CPT code G0416 is not supported in the medical record. Specifically, the medical records indicate 
that surgical pathology, gross examination only was performed. There is a more appropriate code to be billed 
for the services rendered. Based on this information, we decided that Medicare rules for coverage of code G0416 have not been met. Therefore, we decided that the Plan does not have to pay for code G0416 for date of 
service January 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a topical cream provided on August 09, 
2023. 
 
You asked the Plan to waive the coinsurance for a topical cream. You say that you have a very low income. 
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 Medicare Part B covered drugs provided in all places of service. 
 
You have been asked to pay 20% coinsurance for a topical cream. This item/service falls within the Medicare 
Part B covered drugs provided in all places of service 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 79.81 ($399.05 allowed amount x 20% = 
$79.81). Therefore, we decided that the Plan does not have to waive the coinsurance for a topical cream 
provided on August 09, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Koya Dayspring non-pneumatic compression device 
(K1024). 
 
You asked the Plan to pre-approve the Koya Dayspring device. You say that the prescribed treatment is 
medically necessary as demonstrated by the medical documentation The Plan denied your request. The Plan 
says the enrollees condition of chronic lower extremity lymphedema, can be managed with a standard 
pneumatic compression device. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The only Healthcare Common Procedure Coding System (HCPCS) 
codes for PCDs used to treat lymphedema or CVI with ulcers are: E0650, E0651 and E0652. Based on this 
information, we decided that Medicare rules for coverage of the Koya Dayspring device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Koya Dayspring non-pneumatic 
compression device (K1024).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of torus mandibularis (D7473) and general 
anesthesia (D9222 and D9223). 
 
You asked the Plan to pre-approve D7473, D9222, and D9223. You say that you would like the Plan to 
approve this dental work. The Plan denied your request. The Plan says the requested dental services are not 
covered 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. 
 
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 pre-approve the 
removal of torus mandibularis (D7473) and general anesthesia (D9222 and D9223).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) provided on 
September 5, 2023. 
 
You asked the Plan to pay for the CGM. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the enrollee did not meet criteria for the provided CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee did not have an in-
person visit with their treating physician to evaluate their diabetes control and to determine whether the criteria 
for coverage have been met within 6 months prior to ordering the CGM. 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 pay for the continuous glucose monitor (CGM) provided on September 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on June 14, 2023. 
 
You asked the Plan to pay for the lab testing. You say that requesting reconsideration stating please reconsider 
denial for payment as you are an independent lab that collaborates with numerous pain management facilities. 
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 the lab testing provided 
on June 14, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nuclear medicine liver spleen scan.  
 
You asked the Plan to pre-approve a nuclear medicine liver spleen scan. You say that a nuclear medicine liver 
spleen scan is medically necessary. The Plan denied your request. The Plan says a nuclear medicine liver 
spleen scan 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 a nuclear medicine liver spleen scan. 
Our reviewer says that the requested nuclear medicine liver spleen scan is not considered medically reasonable 
and necessary. Our physician reviewer found that the patient is being referred for nuclear medicine liver spleen 
scan to assess for portal hypertension. A nuclear medicine liver spleen scan is not standard of care and not 
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 a nuclear medicine liver spleen scan have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a nuclear medicine liver spleen scan.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 10, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was 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 the laboratory services 
provided on July 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on June 15, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The 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 the office visit provided 
on June 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia for lower intestinal endoscopic procedures, 
endoscope introduced distal to duodenum (00811) provided January 15, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says this claim was submitted after 
the timely filing limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the anesthesia services was not filed until September 5, 2023. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the anesthesia for lower intestinal endoscopic procedures, 
endoscope introduced distal to duodenum (00811) provided January 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213-25 billed for date of service July 7, 
2023. 
 
You asked the Plan to pay for the billed service. The Plan denied your request. The Plan says the billed code is 
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. 
 
We find that the evaluation and management (E&M) code 99213-25 was billed with minor procedure code 
20611. The medical records do not show that code 99213 was a separate and distinct E&M service. Based on 
this information, we decided that Medicare rules for coverage of the billed service have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99213-25 billed for date of service 
July 7, 2023.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the metal crowns (D2751x4). We decided that the Plan does not
have to pre-approve the core build-ups (D2950x4).

You asked the Plan to pre-approve the metal crowns (D2751x4) and the core build-ups (D2950x4). You say
that the enrollee underwent 21 chemotherapy and radiation treatments which contributed to the repeated
breakdown of his lower/upper anterior tooth structure necessitating build-ups and full crown coverage for
proper restoration. The Plan says that the crowns are not medically necessary. The Plan says the core build-ups
are not covered benefits, and the dental plan does not provide benefits to restore damage due to attrition,
abrasion, erosion, and abfraction.

We decided that the Plan has to pre-approve the crowns (D2751x4).

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers crowns when
the services are medically necessary and reasonable.

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 crowns (D2751x4). Our reviewer
says that the crowns (D2751x4) are medically necessary. Our physician reviewer found that there are existing
large fillings on these teeth (on the top and front of these teeth) and the integrity of the filling material is
breaking down and there is decay noted around the margins of the filling material. Based on the information
provided, D2751 for teeth #23,24,25,26 is medically reasonable. Once the existing fillings and decay have been
removed, there will be unsupported tooth structure that will necessitate the requested procedures in order to
restore the teeth to proper function.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of crowns (D2751x4) have been met. Therefore, we decided that the Plan has to
pre-approve the metal crowns (D2751x4). Therefore, we decided that the Plan has to pre-approve .

We also decided that the Plan does not have to pre-approve the core build-ups (D2950x4).

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested core build-ups are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the
core build-ups (D2950x4).

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 drug testing denoted by procedure codes 80307 and G0483, 
billed for date of service April 28, 2023. 
 
You asked the Plan to pay for procedure codes 80307 and G0483. You say that you have billed the services at 
issue 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 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. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of procedure codes 80307 and G0483 
have been met. Specifically, the results of the testing at issue are not documented in the case record. The 
services at issue cannot be verified. Therefore, we decided that the Plan does not have to pay for drug testing 
denoted by procedure codes 80307 and G0483, billed for date of service April 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87899 and 87900 billed for date of service 
December 20, 2022. 
 
You asked the Plan to pay for the billed services. You say that the codes are valid and payable. The Plan denied 
your request. The Plan says one code must be submitted for the panel. 
 
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.  
 
The file shows that a urinary tract infection panel was provided. 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 
procedure codes 87899 and 87900 billed for date of service December 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an associated brachial plexus nerve block (64415). 
 
You asked the Plan to pre-approve an associated brachial plexus nerve block. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 associated brachial plexus nerve 
block. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is no medical need for associated bracial plexus block. The enrollee could use routine post-operation pain medications. 
 
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 associated brachial plexus nerve block have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an associated brachial plexus nerve block (64415).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an annual wellness visit provided on July 
03, 2023. 
 
You asked the Plan to waive the coinsurance for an annual wellness 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 40% 
coinsurance for out-of-network annual wellness visit. 
 
You have been asked to pay 40% coinsurance for an annual wellness visit. This item/service falls within the 
out-of-network annual wellness visit benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total amount you owe is $56.11 ($140.28 allowed amount x 40% = $56.11). 
Therefore, we decided that the Plan does not have to waive the coinsurance for an annual wellness visit 
provided on July 03, 2023.