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

 
We decided that the Plan does not have to pay for procedure code 93280 rendered on February 15, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 93280-26-59 (1 unit) remains not supported. 
 
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 93280 is "Programming device evaluation (in person) 
with iterative adjustment of the implantable device to test the function of the device and select optimal 
permanent programmed values with analysis, review and report by a physician or other qualified health care 
professional; dual lead pacemaker system." 
 
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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that the submitted medical records do 
not include programming device evaluation with iterative adjustment of the device to test function and select 
optimal permanent programmed values with analysis, review and report by the physician or other qualified 
health care professional. Therefore, the billed Current Procedural Terminology (CPT) code and modifiers 
cannot be verified. Review of medical records submitted does not reveal sufficient documentation to authorize 
use of this code. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 93280 rendered on February 15, 2023.
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 you are appealing the denial. The Plan denied your 
request. The Plan says that the enrollee's care needs can be met in a different level of care.  
 
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 enrollee does not require the intensity of services provided at an 
IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and 
regular physician evaluation.  The enrollees care needs can be met at a lower level of care.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 20611 billed for date of service April 11, 2022. 
 
You asked the Plan to pay for code 20611. You say that medical records were provided to support payment. 
The Plan denied your request. The Plan says code 20611 is not supported by the medical 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 20611 is Arthrocentesis, aspiration and/or injection, 
major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent 
recording and reporting. 
 
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 code 20611. Our reviewer says that code 20611 is not 
supported by the medical record. Our reviewer found the supplied medical record does not include a procedure report for the procedure billed.  As a result, our coder was unable to cite to the report as this procedure was not 
found in medical record. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 20611 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 20611 billed for date of service April 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT of the heart and Dipyridamole 
injection provided on May 4, 2023. 
 
You asked the Plan to waive the copayment for the CT scan of the heart and Dipyridamole injection. You say 
that no one mentioned that you had a cost share for the service you received over the office visit copayment 
that you paid. 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 20% 
coinsurance for Medicare covered Part B Chemotherapy drugs and other Part B drugs. 
 
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 $195 
copayment for all other diagnostic and nuclear medicine radiological services. If multiple test types (such as 
CT and positron emission tomography scan (PET) are performed in the same day, multiple copayments will 
apply. If multiple tests of the same type (for example, CT scan of the head and CT scan of the chest) are 
performed in the same day one copayment will apply  
 
You have been asked to pay a total of $195.76 for the CT scan of the heart and Dipyridamole injection.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
May 4, 2023 CT scan $401.65 $195 $195 
May 4, 2023 Dipyridamole 
injection 
$3.80 20% $.76 
TOTAL:    $195.76 
 
This item/service falls within the Medicare Part B prescription drugs and 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. Therefore, we decided that the Plan does not have to waive the copayment for 
the CT of the heart and Dipyridamole injection provided on May 4, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) scan 
of the heart provided on July 12, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI) scan of the heart. You 
say that this will cause you stress and a financial hardship. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copayment for outpatient diagnostic services. 
 
You have been asked to pay a $150 copayment for a magnetic resonance imaging (MRI) scan of the heart. This 
item/service falls within the outpatient diagnostic 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 a magnetic resonance imaging (MRI) scan of the heart provided on July 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient surgery to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the outpatient surgery. You say that you want to have the stent that was 
placed removed by the provider who placed it in your arm. The Plan denied your request. The Plan says the 
enrollee must receive their care from a network provider (for more information about this, see Section 2 in 
Chapter 3). In most cases, care the enrollee receives from an out-of-network provider (a provider who is not 
part of the plans network) will not be 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the outpatient surgery to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit provided on June 7, 2023. 
 
You asked the Plan to pay for the annual wellness visit. The Plan denied your request. The Plan says the benefit 
limit was exhausted because the member previously had this exam on January 4, 2023. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for an annual wellness visit provided on June 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0037U) provided on July 11, 2023. 
 
You asked the Plan to pay for the lab services. You say that this test was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (0037U) provided on July 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the standard wheelchair (K0001) purchased March 
20, 2023. 
 
You asked the Plan to reimburse you for the wheelchair. You say that you were unexpectedly discharged from 
the hospital and you wife was forced to scramble to obtain some equipment after the discharge. The Plan 
denied your request. The Plan says the wheelchair as purchased from a supplier who does n participate with 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for the standard wheelchair 
(K0001) purchased March 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to increase the reimbursement for the scleral cover shell provided on 
June 23, 2023. 
 
You asked the Plan to increase the reimbursement for the scleral cover shell. You say that you should be 
reimbursed more. The Plan denied your request. The Plan says you were reimbursed the correct amount. 
 
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 $950 deductible which applies to prosthetic devices and related 
supplies. Your contract with the Plan also clearly says that you must pay 45% of the Medicare allowed amount 
after the $950 yearly out-of-network deductible for prosthetic devices and related supplies. 
 
 You have been asked to pay $950, which satisfied the deductible for the scleral cover shell. The remaining 
allowed amount is $686.23 ($1,636.23 allowed amount - $950 deductible = $686.23). The item or service you 
asked the Plan to increase the reimbursement for falls within the prosthetic devices and related supplies benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $950 
deductible which applies to prosthetic devices and related supplies. This cost sharing is a contractual obligation 
that had not been met at the time the scleral cover shell was received on June 23, 2023.  
 
You have also been asked to pay $308.80, which is 45% coinsurance of the remaining allowed amount for the 
scleral cover shell. ($686.23 remaining allowed amount x 45% = $308.80). This item/service falls within the 
prosthetic devices and related supplies benefit category. The record shows you should only be reimbursed 
$377.43 ($1,636.23 allowed amount - $1,258.80 cost share = $377.43). This means that you have been 
reimbursed 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 increase the reimbursement for the scleral cover shell provided on June 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter lift for a motor vehicle. 
 
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 the services are not covered. 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. 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 does not serve a purpose that is primarily medical in nature. Furthermore, the 
item is for use outside of the home and is not covered by Medicare for this purpose. Therefore, we decided that 
the Plan does not have to pre-approve a power scooter lift for a motor vehicle.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies.  
 
You asked the Plan to pre-approve incontinence supplies. You say that you disagree with the decision, and you 
were told that services cannot be denied if ordered by a doctor. The Plan denied your request. The Plan says 
this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (93042) provided on April 15, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 93042 is "Rhythm ECG, 1-3 leads; interpretation and 
report only". 
 
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 services. Our reviewer says that the use of code 93042 is 
not supported. Our reviewer found that the records do not clarify that the telemetry reviewed was 1-3 leads and 
that the telemetry review was separate and distinct from the hospital evaluation and management code 99239 that was billed on the same date. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (93042) provided on April 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95165 provided on July 3, 2023. 
 
You asked the Plan to pay for procedure code 95165. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the code 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. 
 
In this case, the CPT Code Manual definition of code 95165 is preparation and provision of antigens for 
allergen immunotherapy; single or multiple antigens. 
 
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 procedure code 95165. Our reviewer says that the billed code 
is not supported. Our reviewer found the documentation does not show that the allergen immunotherapy was 
drawn from a multidose vial. The documentation does not clearly note who administered the immunotherapy. The documentation does not note how much was administered with each dose.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 95165 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 95165 provided on July 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Elan Straight Rail Stairlift. 
 
You asked the Plan to pre-approve a stair glide. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the item is not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve an Elan Straight Rail Stairlift.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the knee orthosis provided on August 09, 
2023. 
 
You asked the Plan to waive the coinsurance for the knee orthosis. You say that you feel this should be covered 
at 100%. 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 20% 
coinsurance for prosthetic devices and related supplies. 
 
You have been asked to pay 20% coinsurance for the knee orthosis. This item/service falls within the prosthetic 
devices 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 you owe is $134.56 ($672.82 allowed amount x 20% = $134.56). Therefore, we 
decided that the Plan does not have to waive the coinsurance for the knee orthosis provided on August 09, 
2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 92950 and 93010 billed for date of service 
October 27, 2022. 
 You asked the Plan to pay for procedure codes 92950 and 93010. You say that this claim is for emergency 
services, so the claim should be reprocessed. The Plan denied your request. The Plan says payment for codes 
92950 and 93010 is bundled into payment for code 92960. 
 
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 codes 
92950 and 93010 are column II codes to column I code 92960. 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 codes 92950 and 93010 billed for 
date of service October 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service August 29, 
2023.  
 
You asked the Plan to pay for procedure code 99497. You say that this code should not have been bundled. The 
Plan denied your request. The Plan says payment for code 99497 is bundled into payment for code 90792. 
 
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 99497 is a column two code to column one code 90792 with a modifier indicator of 0. The column two code is 
therefore not 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 code 99497 billed for date of service August 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral complete series of radiographic images and 
comprehensive evaluation provided on August 28, 2023. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says the dental 
services were received from an out-of-network provider and are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for intraoral complete series of radiographic images 
and comprehensive evaluation provided on August 28, 2023.