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

 
We decided that the Plan does not have to waive the copayment for a specialist office visit and vision care 
provided on March 10, 2023. 
 
You asked the Plan to waive the copayment for a specialist office visit and vision care. You say that you 
disagree with the copayment. 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 $35 
copayment for physician/practitioner services/specialist and a $35 copayment for vision care.  
 
 You have been asked to pay a $35 copayment for a specialist office visit and a $35 copayment for vision care. 
This item/service falls within the physician/practitioner services/specialist and vision care benefit category. 
However, since the allowed amount is less than the standard copayment, you only owe $15 for the vision care. 
The total amount you are being asked to pay $50 ($35 + $15 = $50). 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 and vision care provided on March 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the total electric hospital bed provided on August 18, 2023. 
 
You asked the Plan to pay for the hospital bed. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pay for the total electric hospital 
bed provided on August 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and appliance provided 
on July 20, 2023. 
 
You asked the Plan to pay for the pneumatic compression device and appliance. The Plan denied your request. 
The Plan says this is not covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device and appliance provided on July 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 01, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that these 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 Plan had network providers available who were capable of providing the items/services at issue in this appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 August 01, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 27, 2023. 
 
You asked the Plan to pay for the lab services. You say that you only have one account for this date of service. 
The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was 
correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on August 10, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services provided on June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64447 rendered on March 20, 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 this should not be reported separately. 
 
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 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 procedure report describes 
anesthesia for a total right knee arthroplasty was performed with a spinal block, and a regional block was 
performed at 6:57. Both procedures were performed in the pre-operative area. In this case, this procedure 
would not be performed separately   
 
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 64447 rendered on March 20, 2023.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 64415. We decided that the Plan does not have to pay for 01610.  
 
You asked the Plan to pay for the anesthesia services described by code 01610 and the peripheral nerve block 
injection described by code 64415 billed for date of service July 26, 2023. You say that 01610 and 64415 
should be paid as billed because they are supported in the medical records. The Plan says that 01610 is denied 
because the number of units billed is not supported. 64415 is denied because it is included in code 01610. 
 
We decided that the Plan has to pay for 64415.  
 
The Plan follows Medicare rules. Medicare rules say that a peripheral nerve block may be separately reported 
on the same day as an anesthesia code 0XXXX if the mode of intraoperative anesthesia is general, the 
adequacy of the intraoperative anesthesia is not dependent on the nerve block, it is administered for 
postoperative pain management at the request of the surgeon, and modifier -59 or -XU is appended.  
 
In this case, we confirmed that the peripheral nerve block described by code 64415 was billed on the same date 
as anesthesia code 01610. Records indicate general anesthesia was the primary form of anesthesia used. The 
records clearly indicate that the peripheral nerve block was intended for and administered for postoperative 
pain management at the request of the surgeon. Per Medicare rules, if the mode of intraoperative anesthesia is 
general, as it is in this case, a peripheral nerve block for postoperative pain management performed at the 
request of the surgeon may be reported separately with modifier -59 appended. Separate reporting of a nerve 
block for postoperative pain management does not necessarily require that the nerve block must be 
administered postoperatively. Per Medicare rules, it may be administered preoperatively, intraoperatively, or 
postoperatively. Based on this information, we decided the Medicare rules for coverage of code 64415 have 
been met. Therefore, we decided that the Plan has to pay for 64415.  
 
We also decided that the Plan does not have to pay for 01610. 
 
The Plan follows Medicare rules. Medicare rules say that that providers must report the actual number of units 
provided for each procedure code. 
 
 
 We find that 109 units of CPT code 01610 are not supported in the medical record. The medical record only 
supports 79 units of CPT code 01610. Based on this information, the Medicare rules for coverage of code 
01610 have not been met. Therefore, we decided that the Plan does not have to pay for 01610. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that physical and occupational therapy are both stating 
that this is the best place for the enrollee to receive the care needed. The Plan denied your request. The Plan 
says the enrollee does not meet the criteria for SNF admission.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oncology (cutaneous melanoma) provided on May 22, 2023, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for oncology (cutaneous melanoma). You say that the services should be covered. 
The Plan denied your request. The Plan says this 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 
oncology (cutaneous melanoma) provided on May 22, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the IDgenetix test billed with code 81479 for date of service 
April 20, 2023. 
 
You asked the Plan to pay for the IDgenetix test. You say that this test was necessary and is supported as billed. 
The Plan denied your request. The Plan says this test was not billed with the appropriate CPT code. 
 
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 CPT code 81479 is not supported in the medical record. Specifically, the code assigned to the test 
provided in this case is 81418. Based on this information, we decided that Medicare rules for coverage of the 
IDgenetix test have not been met. Therefore, we decided that the Plan does not have to pay for the IDgenetix 
test billed with code 81479 for date of service April 20, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bupivacaine (J3490) provided on October 20, 2023. 
 
You asked the Plan to pay for bupivacaine. You say that this drug was medically necessary and should be paid. 
The Plan denied your request. The Plan says this is a packaged service which is not paid separately. 
 
The Plan must follow Medicare rules. Medicare rules say that all services integral to accomplishing a procedure 
are considered bundled into that procedure and, therefore, are considered a component part of the 
comprehensive code.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of bupivacaine have not been met. Specifically, bupivacaine is a local anesthetic which would be 
considered integral to, and therefore included in the payment for the injection service or other procedure 
provided. Therefore, we decided that the Plan does not have to pay for bupivacaine (J3490) provided on 
October 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and appliance provided 
on August 4, 2023. 
 
You asked the Plan to pay for the pneumatic compression device and appliance. The Plan denied your request. 
The Plan says this is not covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device and appliance provided on August 4, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an intravenous infusion provided on 
September 13, 2023. 
 
You asked the Plan to waive the copayment for an intravenous infusion. You say that you disagree with the 
copayment. 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 $325 
copayment for each covered in-network surgery in an outpatient hospital. 
 
You have been asked to pay a $325 copayment for an intravenous infusion. This item/service falls within the 
each covered in-network surgery in an outpatient hospital 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 $90 because the Plan is only 
holding you responsible for this amount which is less than the $325 copayment. Therefore, we decided that the 
Plan does not have to waive the copayment for an intravenous infusion provided on September 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 billed for date of service August 10, 
2023.   
You asked the Plan to pay for procedure code 87798. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 87798 is 13. The MAI value for this code is 3. You billed 18 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 87798 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 87798 billed for date of service August 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of a multi-layer compression system 
described by code 29581 performed on August 28, 2023. 
 
You asked the Plan to pay for 29581. You say that 29581 should be paid as billed because it is supported in the 
medical record. The Plan denied your request. The Plan says 29581 is denied because it was applied as a 
dressing after debridement. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules say that casting/splinting/strapping 
CPT codes shall not be reported for application of a dressing after a therapeutic procedure.  
We find that CPT code 29581 is not supported in the medical record. Specifically, the records indicate that 
code 29581 was used to report the application of dressing after the therapuetic procedure described by code 
11042. As such, the denial of 29581 is appropriate. Based on this information, we decided that Medicare rules 
for coverage of 29581 have not been met. Therefore, we decided that the Plan does not have to pay for the 
application of a multi-layer compression system described by code 29581 performed on August 28, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 95938-TC, 95861-TC, and 95940 billed 
for date of service August 22, 2023. 
 
You asked the Plan to pay for procedure code(s) 95938-TC, 95861-TC, and 95940. You say that the claim is 
billed correctly and should be paid. The Plan denied your request. The Plan says these codes are included in the 
facility payment and are not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 95938-TC, 95861-TC, 
and 95940. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 95938-
TC, 95861-TC, and 95940. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 95938-TC, 95861-TC, and 95940 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code(s) 95938-TC, 95861-TC, and 95940 billed for date of service August 22, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for contact lenses (V2500) provided on October 3, 2023. 
 
You asked the Plan to pay for contact lenses. You say that you got contact lenses through the Plan. You also 
say that you are allowed $200 a year, and you have not  purchased contacts all year. The Plan denied your 
request. The Plan says this benefit has been exhausted. 
 
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 $200 toward your purchase of frames or contact lenses. 
 
We looked at the file and the Plan's rules. The Plan rules say they cover one pair of standard lenses and frames 
every year or contact lenses instead of lenses and frames every year. The record shows this benefit was 
exhausted on October 2, 2023. Based on this information, we decided that the Plan's rules for coverage of 
contact lenses have not been met. Therefore, we decided that the Plan does not have to pay for contact lenses 
(V2500) provided on October 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Urine polymerase chain reaction (PCR) testing billed with 
codes s 87500-59, 87641-59, 87798 X12, G0452-26, 87481-59, 87651-59, and 87653-59, for date of service 
May 8, 2023. 
 
You asked the Plan to pay for the Urine PCR testing. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says this lab panel was billed with individual codes 
instead of 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 Urine polymerase chain reaction (PCR) testing billed with codes s 87500-59, 
87641-59, 87798 X12, G0452-26, 87481-59, 87651-59, and 87653-59, for date of service May 8, 2023.