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

 
We decided that the Plan does not have to pay for practitioner services provided on May 31, 2023, billed with 
procedure codes 95861-26, 95937-26, 95938-26, 95939-26, 95955-26, and G0453-59. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be 
reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that M54.2 has an Excludes1 note in relation to M50.123. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the practitioner services provided have not been met. Therefore, we decided that the Plan does 
not have to pay for practitioner services provided on May 31, 2023, billed with procedure codes 95861-26, 
95937-26, 95938-26, 95939-26, 95955-26, and G0453-59.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on July 31, 2023, billed with 
procedure code 99213-CG. 
 You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that the diagnosis code at issue is not appropriate 
as a primary diagnosis. 
 
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code K52.1, described 
as toxic gastroenteritis and colitis. This code is not an appropriate primary diagnosis as the code has a code first 
note indicating to code the underlying condition first. Based on this information, we decided that Medicare 
rules for payment of this claim have not been met. Therefore, we decided that the Plan does not have to pay for 
practitioner services provided on July 31, 2023, billed with procedure code 99213-CG.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the debridement procedure provided on 
August 22, 2023. 
 
You asked the Plan to waive the copayment for the debridement procedure. You say that you should only have 
a $40 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 $350 
copayment for outpatient hospital services. 
 
You have been asked to pay a $350 copayment for the debridement procedure. This item/service falls within 
the outpatient hospital 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 copayment for 
the debridement procedure provided on August 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E06275) and segmental 
pneumatic appliances (E0673) provided on May 25, 2023. 
 
You asked the Plan to pay for the pneumatic compression device and appliances. You say that this device was 
provided for use during the patient's surgery. The Plan denied your request. The Plan says equipment used in a 
facility for a procedure is not separately payable. 
 
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 (E06275) and segmental pneumatic appliances (E0673) 
provided on May 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the oxygen concentrator and the portable 
oxygen system. provided on March 29, 2023. 
 
You asked the Plan to waive the coinsurance for the oxygen concentrator and the portable oxygen system.. You 
say that you disagree with the coinsurance. 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 18% 
coinsurance for in-network durable medical equipment and related supplies. 
 
You have been asked to pay 18% coinsurance for the oxygen concentrator and the portable oxygen system.. 
This item/service falls within the in-network durable medical equipment and related 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. The total amount the 
enrollee owes is $27.10 ($150.55 allowed amount x 18% = $27.10). Therefore, we decided that the Plan does 
not have to waive the coinsurance for the oxygen concentrator and the portable oxygen system. provided on 
March 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on June 8, 2023, billed with 
procedure code 00811-AA-QS. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be 
reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that K92.2 has an Excludes1 note in relation to K57.90. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the practitioner services provided have not been met. Therefore, we decided that the Plan does 
not have to pay for practitioner services provided on June 8, 2023, billed with procedure code 00811-AA-QS.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental services. 
 
You asked the Plan to pay more for the dental services. You say that you would like to request reconsideration 
for payment. 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 the dental services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown for teeth #8 and #9 (D2740). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as you do 
not meet the clinical requirements to be approved. 
 
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 Plan covers the dental 
services 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 dental services. Our physician 
reviewer found there was no clinical documentation included by the provider in the appeal. The cause of why 
the teeth fracture must be determined and treated. If untreated, placing crowns on teeth #8, 9 will not solve the 
issue as crowns can also chip. Crowns will also require removing more healthy tooth structure in order for the 
crowns to be placed on the teeth. There may be more conservative procedures that can help attain the desired 
outcome for the enrollee such as fillings, and bite corrections, and protective mechanisms such as a bite guard 
to protect teeth. Based on the information included crowns (D2740) for teeth #8,9 cannot be considered 
medically necessary. 
 
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 the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown for teeth #8 and #9 (D2740).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve continued SNF care. You say that the enrollee's condition requires a SNF 
admission. The Plan denied your request. The Plan says the enrollee does not meet the criteria for a 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 continued 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 not 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/or skilled therapy on an inpatient basis in a 
skilled nursing facility (SNF) setting. As of 11/12/2023 the enrollee required custodial services. The denial for 
further inpatient skilled care beyond the last covered day is upheld. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable oxygen concentrator provided on March 24, 
2023. 
 
You asked the Plan to pay for the portable oxygen concentrator. You say that you are not allowed to drive 
without oxygen. You say that you live alone and are disabled with a fixed income. The Plan denied your 
request. The Plan says that the rendering provider is not eligible to bill Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are 
enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the portable oxygen concentrator have not been met. Specifically, we found no exception that 
would require the plan to pay for these services. Therefore, we decided that the Plan does not have to pay for 
the portable oxygen concentrator provided on March 24, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Wegovy. 
 
You asked the Plan to pre-approve the medication. You say that Wegovy is medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Wegovy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an OTC COVID-19 test provided on July 27, 2023. 
 
You asked the Plan to pay for an OTC COVID-19 test. You say that the item at issue was a necessity for your 
care. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the 
COVID-19 test at issue is an OTC item. An exception made for OTC COVID-19 tests expired at the conclusion 
of the public health emergency, prior to the date of service at issue. Therefore, we decided that the Plan does 
not have to pay for an OTC COVID-19 test provided on July 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an in-network mental health visit provided 
on April 25, 2023. 
 
You asked the Plan to waive the deductible for a mental health visit. You say that there should be payment on 
this claim, you do not understand why the plan did not cover anything. 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. Your 
contract with the Plan says that there is a $750 deductible which applies to outpatient mental health care. You 
have been asked to pay $350 towards this deductible. 
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient mental health care 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible which applies to outpatient mental health care. This cost sharing is a contractual obligation that had 
not been met at the time a mental health visit was received on April 25, 2023. Therefore, we decided that the 
Plan does not have to waive the deductible for an in-network mental health visit provided on April 25, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CYCLOBENZAPRINE HCL (J8499). 
 
You asked the Plan to pre-approve the medication. You say that the drug is medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve CYCLOBENZAPRINE 
HCL (J8499).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PROLIA (J0897). 
 You asked the Plan to pre-approve PROLIA. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says the step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve PROLIA. Our reviewer says that the 
Plan's step therapy requirements have not been met. Our physician reviewer found the enrollee has not tried 
and failed the required drug. There is no documentation provided indicating that the plans required drug(s) 
would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PROLIA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve PROLIA (J0897).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic consultation (D9310) provided on June 26, 
2023. 
 
You asked the Plan to pay for D9310. You say that you believe the Plan should pay for this. The Plan denied 
your request. The Plan says the rendered dental service is not a covered benefit. 
 
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 a 
diagnostic consultation (D9310) provided on June 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 3, 2023, to April 26, 
2023. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed without the appropriate 
modifier(s). A corrected claim is required. 
 
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 the practitioner services provided have 
been met. Specifically, a corrected claim must be submitted with the appropriate modifier(s) appended to 
reprocess the claim for payment. Therefore, we decided that the Plan does not have to pay for practitioner 
services provided on April 3, 2023, to April 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown for tooth #31 (D2740). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as the 
enrollee disagrees with the denial. The Plan denied your request. The Plan says the services denied correctly as 
the enrollee does not meet the clinical requirements to be approved. 
 
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 Plan covers the dental 
services 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 dental services. Our physician 
reviewer found that the record shows tooth #31 with a small amalgam filling, moderate bone loss around the 
tooth, and wear on the top of the tooth. Teeth with missing tooth structure are not typically repaired with a 
crown as to place a crown, more natural tooth structure needs to be removed. There are more conservative 
treatments that are available to treat wear on teeth. Criteria are unmet. 
 
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 the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown for tooth #31 (D2740).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81209, 81216, 81223, 81238, 81241, 81242, 
81249, 81250, 81279, 81298, 81305, 81307, 81311 81317, 81320, 81321, 81334, 81339, and 81345 provided 
on June 2, 2023. 
 
You asked the Plan to pay for procedure codes 81209, 81216, 81223, 81238, 81241, 81242, 81249, 81250, 
81279, 81298, 81305, 81307, 81311 81317, 81320, 81321, 81334, 81339, and 81345. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says two of the 
billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that D72.818 has an Excludes1 note in relation to D81.89. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for procedure codes 81209, 81216, 81223, 81238, 81241, 81242, 81249, 81250, 81279, 81298, 
81305, 81307, 81311 81317, 81320, 81321, 81334, 81339, and 81345 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 81209, 81216, 81223, 81238, 81241, 81242, 
81249, 81250, 81279, 81298, 81305, 81307, 81311 81317, 81320, 81321, 81334, 81339, and 81345 provided 
on June 2, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve REPATHA SURE. 
 
You asked the Plan to pre-approve the medication. You say that the drug is medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve REPATHA SURE.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve EZETIMIBE (J8499). 
 
You asked the Plan to pre-approve the medication. You say that the drug is medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve EZETIMIBE (J8499).