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

 
We decided that the Plan does not have to pay for procedure code 76140 billed for date of service  
November 3, 2022. 
 
You asked the Plan to pay for procedure code 76140. 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 76140 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 76140 is not valid for Medicare purposes. Therefore, we decided that the Plan does not have to 
pay for procedure code 76140 billed for date of service November 3, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the influenza vaccine provided on October 17, 2022.  
You asked the Plan to pay for the influenza vaccine. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a type of bill is required for home health 
services. 
 
We looked at the file and Medicare rules. These services were rendered in the home health setting. Based on 
this information, we decided that Medicare rules for coverage of the influenza vaccine have not been met. 
Therefore, we decided that the Plan does not have to pay for the influenza vaccine provided on October 17, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11721 billed for date of service December 
21, 2022. 
 You asked the Plan to pay for procedure code 11721. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 11721 is bundled into payment for code 11055. 
 
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 11721 
is a column II code to column I code 11055. 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 11721 billed for date of service December 21, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets the criteria for an IRF admission 
and is at high risk for re-hospitalization if they do not have daily physician oversight and are discharged to a 
lower level of care. The Plan denied your request. The Plan says the requested IRF admission is not medically 
necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
November 14, 2022, and billed with codes 87481, 87491, 87496, 87500, 87529, 87532, 87563, 87591, 87641, 
87651, 87653, 87661, and 87798. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 We looked at the file and Medicare rules. This test was not billed with a singled panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on November 14, 2022, and billed with codes 87481, 87491, 87496, 87500, 87529, 87532, 87563, 
87591, 87641, 87651, 87653, 87661, and 87798.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the remote device evaluation services 
provided on January 04, 2023. 
 
You asked the Plan to reduce the copayment for the remote device evaluation services. You say that this 
copayment should be $25 in 2023. 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 $30 
copayment for in-network outpatient non-radiological diagnostic tests. 
 
You have been asked to pay a $30 copayment for the remote device evaluation services. This item/service falls 
within the in-network outpatient non-radiological diagnostic tests 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 reduce the copayment for the remote device evaluation services provided on January 04, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on December 22, 2022. 
 
You asked the Plan to pay for ophthalmological services. You say that you are requesting the submitted 
documentation be reviewed. 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 ophthalmological 
services provided on December 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the outpatient clinic visit provided on 
January 30, 2023. 
 
You asked the Plan to waive the deductible for the outpatient clinic visit. You say that you should only have a 
$40 copayment for this visit. 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 $150 deductible which applies to in-network specialist 
physician/practitioner services. Your contract with the Plan also says that you must pay a $40 copayment after 
meeting the deductible for in-network specialist physician/practitioner services. 
 You have been asked to pay $85.05 towards the deductible. The item or service you asked the Plan to waive the 
deductible for falls within the physician/practitioner services benefit category. The Plan has followed Medicare 
rules by clearly disclosing in the contract that there is a $150 deductible which applies to in-network specialist 
physician/practitioner services. This cost sharing is a contractual obligation that had not been met at the time 
the outpatient clinic visit was received on January 30, 2023. Therefore, we decided that the Plan does not have 
to waive the deductible for the outpatient clinic visit provided on January 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the specialist office visit provided on 
January 30, 2023. 
 
You asked the Plan to reduce the copayment for the specialist office visit. You say that this should be 
considered a primary care provider visit. 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 $40 
copayment for in-network specialist physician/practitioner services. 
 
You have been asked to pay a $40 copayment for the specialist office visit. This item/service falls within the 
in-network specialist physician/practitioner 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. The record show this claim was approved and you are responsible 
for the specialist copayment. Therefore, we decided that the Plan does not have to reduce the copayment for the 
specialist office visit provided on January 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 31, 2023. 
 
You asked the Plan to pay for laboratory services. You say that this was medically necessary and 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 January 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the health club membership provided from 
January 1, 2023, through April 1, 2023. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plans denial for payment. The Plan denied your request. The Plan says these services are 
not a covered benefit.  
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.   
 
The Plans rules for coverage of gym benefits have not been met because the membership purchased in this 
case is not a covered benefit. Specifically, the Plans contract states that coverage is provided for a fitness 
membership through the Plans select fitness provider.  
  
 
However, in this case, you purchased a gym membership from an out-of-network provider. Additionally, the 
Plans contract states that enrollees receive $390 every quarter on a Flex card for qualifying fitness expenses. 
Therefore, you may utilize this card for fitness expenses. Therefore, we decided that the Plan does not have to 
issue reimbursement for the health club membership provided from January 1, 2023, through April 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 glucose monitor. 
 
You asked the Plan to pre-approve the Dexcom G7 glucose monitor. You say that you have a history of severe 
hypoglycemia and your glucose levels drastically change throughout the day and often feel dizzy or weak. You 
also say that you experienced a life-threatening episode and could have been prevented if you had the Dexcom 
G7 CGM.  The Plan denied your request. The Plan says at this time, the G7 is not an available device. The Plan 
currently provides the Dexcom G6. You were also authorized for the Dexcom G6 in January of 2022. You will 
be eligible for a replacement device if there is a medical need that warrants a different device OR the device is 
no longer functioning AND is out of warranty. The Plan also says the Dexcom CGM has a 3-year warranty. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement due to wear is not covered during 
the reasonable useful lifetime of the equipment. During the reasonable useful lifetime, Medicare does cover 
repair up to the cost of replacement (but not actual replacement) for medically necessary equipment owned by 
the beneficiary. We looked at the file and Medicare rules. The record does not show that your current CGM has sustained loss 
or irreparable damage, and it is less than 5 years old so it is still within the reasonable useful lifetime. Based on 
this information, we decided that Medicare rules for coverage of the Dexcom G7 glucose monitor have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G7 glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) purchased from 
the out-of-network (OON) provider on December 13, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the items are not payable as they 
were purchased from an out-of-network provider.  
 
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 issue reimbursement 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 at issue in this appeal.   
 
The Plan did not pre-approve the items at issue. We found no exception that would require the Plan to issue 
reimbursement for these items. Therefore, we decided that the Plan does not have to issue reimbursement for 
the hearing aids (V5261) purchased from the out-of-network (OON) provider on December 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a drug test provided on November 03, 2022. 
 
You asked the Plan to pay for a drug test. You say that the 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 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 a drug test provided on 
November 03, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychiatric diagnostic evaluations, and psychotherapy 
services provided on July 26, 2022, to August 16, 2022. 
 
You asked the Plan to pay for psychiatric diagnostic evaluations, and psychotherapy services. You say that you 
have not received any reimbursement for services rendered. 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 psychiatric diagnostic 
evaluations, and psychotherapy services provided on July 26, 2022, to August 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory drug testing provided on November 09, 2022. 
 
You asked the Plan to pay for laboratory drug testing. You say that this was medically necessary and 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 drug testing 
provided on November 09, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on September 13, 2022. 
 
You asked the Plan to pay for nursing facility care. You say that this is supported in the records. 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 nursing facility care 
provided on September 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on January 26, 2023. 
 
You asked the Plan to pay for wound care supplies. You say that you say that wound care supplies are a 
separately billable expense that does not requeire authorization or 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 January 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment and abutment supported 
porcelain/ceramic crown (D6057, D6058) provided on January 25, 2023. 
 
You asked the Plan to pay for 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 they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a custom 
fabricated abutment and abutment supported porcelain/ceramic crown (D6057, D6058) provided on January 
25, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
December 10, 2022, to December 24, 2022.  
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that your stay was 
prolonged because you were denied rehabilitation services. 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 per day for days 1-4 of each inpatient hospital stay. Your contract with the Plan also says that you then pay a $0 copayment per day for any additional days of the same inpatient hospital stay. 
 
You have been asked to pay a $325 copayment per day for days 1-4 of the inpatient hospital stay. This 
item/service falls within the inpatient hospital care benefit category. You have not been charged after day four 
or for the day you were discharged. You have been asked to pay a total of $1,300 ($325 copayment per day x 4 
days = $1,300). 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 inpatient hospital stay provided from 
December 10, 2022, to December 24, 2022.