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

 
We decided that the Plan does not have to pay for the laboratory services provided on June 22, 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 June 22, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx (F1CDx) 324 gene profiling test provided on 
August 24, 2023. 
 
You asked the Plan to pay for the F1CDx testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says that since the F1CDx gene panel analyzes 324 genes, it must be considered 
experimental and investigational  and therefore, not covered by the MA program. 
 
The Plan must follow Medicare rules. Medicare rules say that the FoundationOne CDx (F1CDx) is covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the Plan states that this testing is not 
covered. However, the DEX Diagnostics Exchange Registry lists this testing as covered. No other rationale was 
provided to support the Plan's denial. Based on this information, we decided that Medicare rules for coverage 
of the F1CDx testing have been met. Therefore, we decided that the Plan has to pay for the FoundationOne 
CDx (F1CDx) 324 gene profiling test provided on August 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99285) provided 
on May 20, 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 service at issue in this case is not supported by the medical records. Our reviewer found 
that the records do not support a medically appropriate history, examination, or high level of 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 May 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on July 
10, 2023. We also decided that the Plan does not have to pay more for the limited oral evaluation - problem 
focused (D0140), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth (D7210), and 
extraction, erupted tooth or exposed root (D7140) provided on July 10, 2023. 
 
 You asked the Plan to pay for the panoramic radiographic image. You also asked the Plan to pay more for the 
limited oral evaluation - problem focused (D0140), extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth (D7210), and extraction, erupted tooth or exposed root (D7140). You say that you were 
referred to this provider by your dentist to have your teeth removed. You also say that you were told you would 
have to be reimbursed by the plan. The Plan denied your request. The Plan says your benefit for the panoramic 
radiographic image has already been exhausted. The Plan also 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the panoramic radiographic image was exhausted on date of service June 22, 2023. 
Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330) 
provided on July 10, 2023.  
 
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 the limited oral evaluation - problem focused 
(D0140), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth (D7210), and 
extraction, erupted tooth or exposed root (D7140) provided on July 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medically tailored meals. 
 
You asked the Plan to pre-approve the medically tailored meals. You say that the Plan's benefits are not 
enough. You say that you have high blood pressure, severe back problems, arthritis, and are old. The Plan 
denied your request. The Plan says does not meet criteria. The Plan says there is no inpatient admission or 
submitted documentation of increased hospitalization risk. 
 
Medicare generally does not cover medically tailored meals. However, the Plan offers a medically tailored 
meals benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The 
Plan covers medically tailored meals if an enrollee has had a recent hospitalization admission or an increased 
hospitalization risk. 
 
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 medically tailored meals. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found there is no documented 
risk of increased hospitalization risk. You have hypertension but not clear would benefit from medically tailored meals. 
 
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 medically tailored meals have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the medically tailored meals.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360 and 88381 billed for 
date of service October 31, 2022. 
 You asked the Plan to pay for procedure code(s) 88341, 88342, 88360 and 88381. You say that you have billed 
the services at issue correctly. The Plan denied your request. The Plan says this code is included in the facility 
payment and is 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 the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360 
and 88381. 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) 88341, 
88342, 88360 and 88381. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88341, 88342, 88360 and 88381 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88341, 88342, 88360 and 88381 billed for date of service October 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor, and related supplies billed 
for date of service June 27, 2023. 
 
You asked the Plan to pay for the billed items. You say that the required documentation was provided. 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 relevant medical records which support medical necessity for the supplies provided 
in this case. The records do not show that the enrollee uses insulin, has a history of problematic hypoglycemia, 
or has had physician visit within 6 months before the items were provided that shows the treating physician 
ordered the items as part of the enrollees treatment plan. 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 continuous glucose monitor, and related supplies billed for date of service June 27, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the alcohol counseling (H0015) provided 
on June 15, 2021, to June 18, 2021. 
 
You asked the Plan to waive the coinsurance for the alcohol counseling (H0015). You say that the cost share is 
wrong. 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 30% 
coinsurance for outpatient substance abuse services. 
 
You have been asked to pay 30% coinsurance for the alcohol counseling (H0015). This item/service falls 
within the outpatient substance abuse services benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for the alcohol counseling (H0015) provided on June 15, 2021, to June 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S2900 billed for date of service August 11, 
2023. 
 
You asked the Plan to pay for procedure code S2900. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S2900 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S2900 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S2900 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S2900 billed for date of service August 11, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 70450 and 99053 billed for date of service 
August 14, 2023. 
 
You asked the Plan to pay for the billed services. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says the codes are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
In this case, we have confirmed that code 70450 is a column II code to column I code 70496. Code 70450 has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met.  
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
70450 and 99053 billed for date of service August 14, 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 January 
20, 2023. 
 
You asked the Plan to waive the copayment for a specialist office visit. 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. 
 
You have been asked to pay a $35 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/ specialist 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 January 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 27, 2023. 
 
You asked the Plan to pay for laboratory services. You say that the services should be covered. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on July 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of excess skin and subcutaneous tissue. 
 
You asked the Plan to pre-approve removal of excess skin and subcutaneous tissue. You say that you are 
requesting reconsideration for the denied claim. The Plan denied your request. The Plan says you do not meet 
the requirements for approval. 
 
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 removal of excess skin and 
subcutaneous tissue. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found you have a history of gastric bypass 
surgery, heart disease, and diabetes who is requesting tummy tuck, breast lift surgery, with panniculectomy. 
However, the provided documentation did not clearly support the panniculectomy as there was no reported skin maceration, infection, or report of difficulty walking or other functional impairment directly related to the 
excess skin to justify this request. Therefore, the removal of excess skin and subcutaneous tissue 
(panniculectomy) (15830) will be considered not medically necessary based on the provided documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of removal of excess skin and subcutaneous tissue have not been met. Therefore, 
we decided that the Plan does not have to pre-approve removal of excess skin and subcutaneous tissue.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial preventive physical examination; face-to-face visit, 
services limited to new beneficiary during the first 12 months of Medicare enrollment (G0402) provided on 
August 1, 2023. 
 
You asked the Plan to pay for the annual wellness visit (AWV). You say that this was your first annual 
wellness visit for the year. You say that your last annual visit was in July 2022 which was 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 initial preventive physical examination; face-
to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment (G0402) 
provided on August 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on August 31, 2023. 
 
You asked the Plan to pay for wound care supplies. You say that you were not able to obtain a referral. 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 wound care supplies 
provided on August 31, 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 April 15, 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 service at issue in this case is not supported by the medical records. Our reviewer found 
the records support a medically appropriate history and/or examination but not high level of 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 April 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nail debridement (11721) provided on March 28, 2023. 
 
You asked the Plan to pay for the nail debridement (11721). You say that the service 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 nail debridement 
(11721) provided on March 28, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound (76770) provided on August 
18, 2023. 
 
You asked the Plan to waive the copayment for the ultrasound (76770). You say that the cost share is wrong. 
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 $150 
copayment for outpatient diagnostic tests and therapeutic services andsupplies. 
 
You have been asked to pay a $150 copayment for the ultrasound (76770). This item/service falls within the 
outpatient diagnostic tests and therapeutic services andsupplies 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. However, the allowed amount is less than the 
copay, so you only owe $127.84. Therefore, we decided that the Plan does not have to waive the copayment for 
the ultrasound (76770) provided on August 18, 2023.