Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair accessory electronic connection 
between wheelchair controller and two or more power seating system motors (E2311). 
 
You asked the Plan to pre-approve power wheelchair accessory electronic connection between wheelchair 
controller and two or more power seating system motors. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that electronic connection between wheelchair controller 
and two or more power seating system motors is only covered for certain indications. 
 
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 power wheelchair accessory electronic 
connection between wheelchair controller and two or more power seating system motors. Our reviewer says 
that the documentation does not support that the requested item is medically reasonable or necessary. Our 
physician reviewer found the enrollee has hypertension, heart failure and arthritis. The enrollee has limited self 
propulsion in a wheelchair. The enrollee is able to feed herself. The documentation shows that the enrollee has 
adequate strength to manage standard power drives. Therefore, the enrollee does not meet criteria for the 
requested item. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power wheelchair accessory electronic connection between wheelchair 
controller and two or more power seating system motors have not been met. Therefore, we decided that the Plan does not have to pre-approve power wheelchair accessory electronic connection between wheelchair 
controller and two or more power seating system motors (E2311).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88305 billed for date of service February 27, 
2023. 
 You asked the Plan to pay for procedure code 88305. You say that you disagree with the Plan's denial. 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 88305. This means there 
is both a professional and technical component for the CPT code. In this case, an appropriate modifier to 
indicate the professional component has not been billed with CPT code 88305. Based on this information, we 
decided that Medicare rules for coverage of procedure code 88305 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 88305 billed for date of service February 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service February 21, 
2023. 
 
You asked the Plan to pay for procedure code 88341. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 88341 is bundled into payment for code 88360. 
 
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 88341 
is a column II code to column I code 88360. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 88341 billed for date of service February 21, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive part of the cost share the outpatient surgery services provided 
on June 2, 2023. 
 
You asked the Plan to waive part of the cost share the outpatient surgery. You say that this surgery was done at 
an ambulatory surgery center. You say that your copay should be $200. You say that you have called the billing 
provider multiple times to have this fixed. You also say that they advise the billing is done at the hospital so 
they can bill it as outpatient hospital. 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 $300 
copayment for outpatient surgery.  
 You have been asked to pay a $300 copayment for the outpatient surgery. This service falls within the 
outpatient surgery benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan and how the provider billed this claim.. 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 
part of the cost share the outpatient surgery services provided on June 2, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
  You asked the Plan to pre-approve Vabysmo. The Plan denied your request. The Plan says the enrollee has not 
tried or cannot use bevacizumab. 
 
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 Vabysmo. Our reviewer says that there 
is no indication that the enrollee has tried and failed the required drug. Our physician reviewer found there is 
no indication that the Plan's required drug would likely be less effective 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 Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulations (98941) provided from June 
29, 2023, to August 10, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the chiropractic care. You say that the services were medically necessary. The 
Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the chiropractic manipulations (98941) provided 
from June 29, 2023, to August 10, 2023, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 3, 2023, to 
February 1, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you attempted to follow timely 
filing requirements. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA as required. Based on this information, we find that the Medicare rules for 
payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for 
the home health services provided from January 3, 2023, to February 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99292 billed for date of service May 6, 2023. 
 
You asked the Plan to pay for procedure code 99292. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 99292 is bundled into payment for code 92950. 
 
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 99292 
is a column II code to column I code 92950. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99292 billed for date of service May 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinary tract infection panel test billed for date of service 
August 10, 2023. 
 
You asked the Plan to pay for the billed testing. You say that the results show all work was performed. 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.  
 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 urinary tract infection panel test billed for date of service August 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the bifocal eyeglass lens (V2203) and anti-reflective 
coating (V2750) provided on July 6, 2023. 
 
You asked the Plan to pay more for bifocal eyeglass lens and anti-reflective coating. You say that this is not a 
situation where you purposely exceeded your coverage amount in order to have a second pair of glasses. The 
Plan denied your request. The Plan says your optical frame allowance 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 provides a $250 allowance every calendar year that you can use to pay for eyewear to 
correct vision. If the eyewear you purchase costs more than $250, you pay the difference.  
We looked at the file and the Plan's rules. Specifically, the record shows that the total for the glasses (including 
frames, bifocal lens, and anti-reflective coating) was $467.00, and the Plan applied the full $250.00 eyewear 
allowance to this purchase. Based on this information, we decided that the Plan's rules for coverage of bifocal 
eyeglass lens and anti-reflective coating have not been met. Therefore, we decided that the Plan does not have 
to pay more for the bifocal eyeglass lens (V2203) and anti-reflective coating (V2750) provided on July 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis - adult (D1110) provided on September 19, 
2023. 
 
You asked the Plan to pay for the dental service. You say that you are receiving the extra dental care because 
you have burning mouth syndrome with oral lesions. The Plan denied your request. The Plan says your benefit 
for the requested service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested service was exhausted on dates of service March 21, 2023, and June 15, 
2023. Therefore, we decided that the Plan does not have to pay for the prophylaxis - adult (D1110) provided on 
September 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 81120, 81121, 
81170, 81191, 81192, 81193, 81210. 81235, 81270, 81275, 81276, 81309, 81311, 81314, 81272,81401, 81403, 
81404, and 81479 for date of service July 17, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier.  
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services billed 
with codes 81120, 81121, 81170, 81191, 81192, 81193, 81210. 81235, 81270, 81275, 81276, 81309, 81311, 
81314, 81272,81401, 81403, 81404, and 81479 for date of service July 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85060 billed for July 6, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a PC/TC indicator of 8 identifies professional 
component of clinical laboratory codes for which separate payment may be made only if the physician 
interprets an abnormal smear for hospital inpatient.  
 
We looked at the file and Medicare rules. Billed procedure code 85060 has a PC/TC indicator of 8 and the file 
shows the services were not performed for a hospital inpatient but in an office setting. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 85060 billed for July 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occlusal guard - hard appliance, full arch (D9944) provided 
on September 19, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service November 29, 2022. 
Therefore, we decided that the Plan does not have to pay for occlusal guard - hard appliance, full arch (D9944) 
provided on September 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sedation services (99152) for medial branch blocks. 
 
You asked the Plan to pre-approve sedation services. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not covered. 
 
The Plan follows Medicare rules. Medicare rules say that general anesthesia is considered not reasonable and 
necessary for facet joint interventions. Neither conscious sedation nor monitored anesthesia care (MAC) is 
routinely necessary for intraarticular facet joint injections or medial branch blocks and are not routinely 
reimbursable. Individual consideration may be given on redetermination (appeal) for payment in rare, unique 
circumstances if the medical necessity of sedation is unequivocal and clearly documented in the medical 
record.  
 
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 sedation services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found there is no documentation of 
medical necessity for the use of moderate sedation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sedation services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve sedation services (99152) for medial branch blocks.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes G0453 and A4556 billed for date of service 
May 23, 2023. 
 
You asked the Plan to pay for the billed services. You say that the codes can be billed together. The Plan 
denied your request. The Plan says the billed 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 G0453 is a column II code to column I code 95940. Code G0453 has 
not been billed with an appropriate modifier to bypass the edit. We find that procedure code A4556 has a status 
indicator of B on the Physician Fee Schedule. This means that procedure code A4556 is not separately payable. 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes G0453 and A4556 billed for date of service May 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code E0483-RR billed for date of service June 1, 
2023. 
 
You asked the Plan to pay for the billed service. You say that supporting documentation was provided. The 
Plan denied your request. The Plan says an appropriate modifier was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We find that CPT code E0483-RR is not supported. The claim at issue was not billed with a modifier indicating 
the month of rental. 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 E0483-
RR billed for date of service June 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the platelet injection service and the supplies and materials 
provided on January 4, 2023, by an out-of-network OON provider.  
 
You asked the Plan to pay for the platelet injection service and the supplies and materials. You say that you are 
requesting reconsideration of the denied claim. The Plan denied your request. The Plan says the service was not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the platelet injection service and the supplies and 
materials provided on January 4, 2023, by an OON provider.