Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes D5731 and D5765, nor does the Plan have 
to pay more for procedure codes D5851, D5760, D5422, D0220 and D0230 provided from May 30, 2023, to 
July 18, 2023.  

You asked the Plan to pay for procedure codes D5731 and D5765, nor pay more for procedure codes D5851, 
D5760, D5422, D0220 and D0230. You say that this provider treated your horribly. You also say that the 
provider performed work that you asked them not to do. The Plan denied your request. The Plan says your 
benefit for the requested item or service has already been exhausted. The Plan also says you are responsible for 
any charged amount above the Plan's 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 Plan's 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 procedure code D5731 was exhausted on date of service May 30, 2023. The record 
shows your benefit for procedure code D5765 was exhausted on date of service June 13, 2023. Additionally, 
you have been asked to pay the difference between the out-of-network provider's charges and the Plan's 
payment for procedure codes D5851, D5760, D5422, D0220 and D0230. 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 for procedure codes D5731 and D5765, nor does the Plan have to pay more for procedure codes D5851, 
D5760, D5422, D0220 and D0230 provided from May 30, 2023, to July 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 17, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration of the 
denied claim. 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 July 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 28, 2023, to July 19, 
2023. 
 
You asked the Plan to pay for laboratory services. You say that this service is supported in the records proving 
medical necessity. 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 June 28, 2023, to July 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an echocardiogram (93306, 93356) and 
heart monitoring (93244, 93242) provided on September 02, 2023. 
 
You asked the Plan to waive the copayment for an echocardiogram (93306, 93356) and heart monitoring 
(93244, 93242). 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 $30 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $30 copayment for an echocardiogram (93306, 93356) and heart monitoring 
(93244, 93242). This item/service falls within the outpatient diagnostic tests and therapeutic services and 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. You were charged $60 ($30 x 2 radiology services) Therefore, we decided that the Plan does not have to 
waive the copayment for an echocardiogram (93306, 93356) and heart monitoring (93244, 93242) provided on 
September 02, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the cervical collar provided on July 24, 
2023. 
 
You asked the Plan to waive the coinsurance for the cervical collar. You say that you did not receive the item. 
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 10% 
coinsurance for durable medical equipment and related supplies. 
 
You have been asked to pay 10% coinsurance for the cervical collar. This item/service falls within the 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 you owe is $27.61 ($276.07 allowed amount x 10% = 
$27.61). Therefore, we decided that the Plan does not have to waive the coinsurance for the cervical collar 
provided on July 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 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 June 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinary tract infection panel provided on March 8, 2023. 
 
You asked the Plan to pay for the urinary tract infection panel. 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 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 provided on March 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 99223 billed for date of service June 28, 2023. 
 
You asked the Plan to pay for the billed code. You say that the visit is separately payable. 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 CPT code. 
 We looked at the file and the rules. We find that CPT code 99223 was provided one day prior to major surgical 
procedure 27245. The claim at issue was not billed with a modifier as required to identify a visit which results 
in the initial decision to perform surgery. Based on this information, we decided that Medicare rules for 
coverage of the billed code have not been met. Therefore, we decided that the Plan does not have to pay for 
99223 billed for date of service June 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee brace provided on April 14, 2023. 
 
You asked the Plan to pay for the knee brace. You say that The item 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 the knee brace provided 
on April 14, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are necessary. The Plan 
denied your request. The Plan says the criteria for an LTACH admission has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving with current treatment and requires additional 
acute care services that can safely be provided at the current facility until more stable and appropriate for 
transfer to a lower level of care. The enrollee does not require services at the LTACH that are not already 
available.  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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Kinnex microprocessor. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a K3 microprocessor foot is covered when 
specific criteria are met. 
 
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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the documentation from the enrollee's 
physician and prosthetist corroborate that current Highlander foot described by code L5981 is not meeting his 
current needs and functional level. He has gained 30 pounds since the fitting, which could result in the current 
foot being under-categorized and providing insufficient energy return due to the increase in weight. An under-
catergorized or inefficient foot could lead to an increase in socket pressure and more importantly, safety 
concerns. The K3 level foot replacement is necessary, as the previously provided foot does not meet the 
enrollee's functional level needs. 
 
We looked at this physician's review, the file, and Medicare rules.  Based on this information, we decided that Medicare rules for coverage of these services have been met. 
Therefore, we decided that the Plan has to pre-approve a Kinnex microprocessor.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from IRF services to 
optimize his level of functioning prior to returning home. The Plan denied your request. The Plan says the 
enrollee does not meet the requirements for an IRF admission.  
 
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 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. The enrollee has had a decline from his baseline level of function 
and may benefit from occupational and physical therapies, but he does not require the intensity of therapies 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foam caster tires, shock absorbers for manual 
wheelchair, and propulsion tires. 
 
You asked the Plan to pre-approve foam caster tires, shock absorbers for manual wheelchair, and propulsion 
tires. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says the 
requested features are needed for outdoor use. The Plan also says that DME is only covered when it is needed 
in the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve foam caster tires, shock absorbers for manual wheelchair, and propulsion tires.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care visit. 
 
You asked the Plan to waive the copayment for the urgent care visit. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $40 copayment for urgently needed services.  
 
The enrollee has been asked to pay a $40 copayment for the urgent care visit. This item/service falls within the 
urgently needed services benefit category. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
the urgent care visit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 Sensor. 
 
You asked the Plan to pre-approve a Dexcom G7 Sensor. You say that due to the dropping of the enrollee's low 
blood sugars, the enrollee needs the requested Dexcom CGM. The Plan denied your request. The Plan says the 
enrollee is not using a stand-alone receiver, therefore, a Dexcom G7 cannot be covered. 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee must be using a stand-
alone receiver or a stand-alone receiver in conjunction with a smartphone for the Dexcom G7 to be eligible for 
coverage by Medicare. The records show the enrollee is not using a stand-alone receiver. Based on this 
information, we decided that Medicare rules for coverage of a Dexcom G7 Sensor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Dexcom G7 Sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; genicular 
nerve branches, including imaging guidance, when performed (64454). 
 
You asked the Plan to pre-approve a genicular nerve block. You say that you are requesting reconsideration 
and have attached medical records for review. The Plan denied your request. The Plan says a review of the 
current medical literature does not support this service to be reasonable and necessary. 
 
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 a genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has chronic right knee pain. She is morbidly obese and had a partial knee 
replacement in 2016. She takes Gabapentin for pain. This is considered an experimental/ investigational 
procedure at this time. It is the subject of ongoing clinical trials. Therefore, the request is deemed not medically 
reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, 
including imaging guidance, when performed (64454).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87471-59 and 87640-59) provided 
August 8, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
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 87471 is infectious agent detection by nucleic acid (DNA 
or RNA); Bartonella henselae and Bartonella quintana, amplified probe technique.  

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the laboratory services. Our reviewer found code 87640-59, 
it does not meet criteria for billing or reimbursement consideration CPT 87640 has a bundled relationship with 
CPT code 87641, which was also performed on August 8, 2023. NCCI rules does allow for the use of a 
modifier to unbundle these services providing the medical documentation validates the use of an appropriate 
modifier. In this case, the medical records do not include sufficient documentation to validate 87640 was 
performed as a distinct or separate service, independent of 87641; therefore, the use of a 59 modifier is not 
appropriate.  
 
Furthermore, for code 87471, it does not meet criteria for billing or reimbursement consideration. The medical 
records provided does not include sufficient documentation to validate that Infectious agent detection by 
nucleic acid (DNA or RNA); Bartonella henselae and Bartonella quintana, amplified probe technique was 
performed on August 8, 2023; therefore, this procedure cannot be verified 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (87471-59 and 87640-59) provided August 8, 2023.