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

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
January 10, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service January 10, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Hyalgan (J7321). 
 You asked the Plan to pre-approve Hyalgan. You say that Hyalgan is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says step-therapy rules for coverage of Hyalgan have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Hyalgan. Our reviewer says that 
Hyalgan is not medically reasonable and necessary in this case. Our physician reviewer found that the Plan 
requires a trial of drugs Gel-One, Synvisc or Synvisc-One before they will approve the requested drug. In this 
case, the enrollee has not tried and failed the required drugs. There is no documentation provided indicating 
that the Plans required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Hyalgan (J7321).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 88332 provided on October 26, 2022. 
 
You asked the Plan to pay for procedure code 88332. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination 
within the allotted time frame. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has not provided enough evidence to support the denial of 
payment for procedure code 88332 based on Medicare criteria. Therefore, we decided that the Plan has to pay 
for procedure code 88332 provided on October 26, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99232) provided on December 23, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as 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 find that CPT code 99232 is not supported in the medical record. Specifically, Diagnosis codes G47.33 
(Obstructive sleep apnea (adult) (pediatric)) and E66.2 (Morbid (severe) obesity with alveolar hypoventilation),  
should not be reported together as they have an exclude note. Based on this information, we decided that 
Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan 
does not have to pay for physician services (99232) provided on December 23, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on December 14, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that this claim should be reconsidered. The Plan 
denied your request. The Plan says you have not supplied sufficient information to process this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the ambulance services have been met. 
Specifically, you have failed to supply any trip reports or medical records supporting the billing of these 
services, despite multiple requests for such documentation from the Plan. Therefore, we decided that the Plan 
does not have to pay for ambulance services provided on December 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81225, 81306, 81335, 81226) provided on 
August 9, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so 
1 procedure code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were submitted for a single panel. Based 
on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services (81225, 81306, 81335, 81226) 
provided on August 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 billed for date of service December 
19, 2022. 
 You asked the Plan to pay for procedure code 99214. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 99214 is bundled into payment for code 99215. 
 
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 99214 
is a column II code to column I code 99215. 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 99214 billed for date of service December 19, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ActiGraft (15271, 15272, Q4100). 
 
You asked the Plan to pre-approve ActiGraft. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan follows Medicare rules. Medicare rules say that Medicare covers application of CTPS to Ulcers or 
Wounds with Failed Response that meet certain criteria. 
 
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 ActiGraft. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found available literature on this product in the 
setting of chronic ulcer treatment is limited and there was insufficient high-quality evidence supporting its use 
as a standard treatment for similar clinical scenarios. The enrollee does not meet the coverage criteria in the 
LCD.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ActiGraft have not been met. Therefore, we decided that the Plan does not have 
to pre-approve ActiGraft (15271, 15272, Q4100).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on November 28, 2022. 
 
You asked the Plan to pay for the medical services. You say that this provider has been paid for services in the 
past, so this claim should be reprocessed. The Plan denied your request. The Plan says the provider who billed 
for this service is not eligible to bill Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that the following provider types are eligible to 
receive Medicare payment: physicians, physician assistant, nurse practitioner, clinical nurse specialist, nurse 
midwife, and clinical psychologists. 
 
In this case, it appears as though the provider of the services at issue has two separate taxonomy codes: one that 
designates them as a Registered Nurse, and one that designates them as a Nurse Practitioner.  For the claim in 
dispute, it was billed with the taxonomy for the Registered Nurse listing.  Registered nurses are not permitted 
to bill under Medicare rules, which is why this claim cannot be paid.  If you wish to submit a corrected claim 
with the Nurse Practitioner taxonomy code, you can do that with the Plan directly.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided on November 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 1, 2022. 
 
You asked the Plan to pay for the lab services. You say that these lab services were needed to determine the 
course of treatment. 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 provided on July 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the drug injections and medical supplies 
provided on January 9, 2023. 
 
You asked the Plan to waive the coinsurance for the drug injections and medical supplies. You say that you 
were aware of the $275 copayment, but not aware of these coinsurance amounts. 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 out-of-network Medicare Part B drugs. Your contract with the Plan also clearly says that enrollees must pay 20% coinsurance for out-of-network diagnostic tests and procedures. 
 
You have been asked to pay 20% coinsurance for the drug injections. This item/service falls within the 
Medicare Part B drugs benefit category. You have also been asked to pay 20% coinsurance for the medical 
supplies. This item/service falls within the outpatient diagnostic tests and therapeutic 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 coinsurance for the drug injections and medical supplies provided on 
January 9, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve transluminal balloon angioplasty (37248).  
 
You asked the Plan to pre-approve transluminal balloon angioplasty. You say that the enrollee is unable to 
perform daily activities due to the severity of issues The Plan denied your request. The Plan says that there is 
no evidence of stenosis or external compression of the venous system on the right lower extremity. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 transluminal balloon angioplasty. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found that the enrollee has severe edema of the lower extremities bilaterally with 
symptoms severe enough to impact daily activities. There is no evidence of deep vein thrombosis or significant 
superficial reflux. Symptoms suggestive of claudication are documented with triphasic dorsalis pedis and 
posterior tibial waveforms noted on ultrasound suggesting satisfactory arterial perfusion bilaterally. In this 
setting it would be reasonable to rule out and possibly treat iliac venous occlusive disease if present. 
Claudication due to venous obstruction has a bursting nature and could be quite debilitating. Recommend 
coverage of venography and associated diagnostic testing with provisional coverage of venous angioplasty and 
stenting recognizing that final coverage will require appropriate documentation of findings at the time of the 
venogram. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transluminal balloon angioplasty have been met. Therefore, we decided that the 
Plan has to pre-approve transluminal balloon angioplasty (37248).   
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
July 25, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service July 25, 2022.
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 
January 14, 2023, to January 19, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you are on a fixed 
income, and were not informed about this copayment. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $375 
copayment per day for days 1-5 of each inpatient hospital stay. Your contract with the Plan also clearly says you then pay a $0 copayment per day for days 6-90 of each inpatient hospital stay. 
 
You have been asked to pay a $375 copayment per day for days 1-5 of the inpatient hospital stay. This 
item/service falls within the inpatient hospital care benefit category. You have not been asked to pay after day 
five or for the day you were discharged. You have been asked to pay a total of $1,875 for the inpatient hospital 
stay ($375 copayment per day x 5 days = $1,875). 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 January 14, 2023, to January 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions and unspecified adjunctive procedure (D7210, 
D7140, D9999) provided on November 29, 2022. 
 
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 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 January 4, 2022. 
Therefore, we decided that the Plan does not have to pay for extractions and unspecified adjunctive procedure 
(D7210, D7140, D9999) provided on November 29, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tukysa. 
 
You asked the Plan to pre-approve Tukysa. You say that the claim should be reprocessed. The Plan denied your 
request. The Plan says that self- administered drugs do not fall under Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tukysa.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary and mandibular denture 
(D5110/D5120) provided on February 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were unaware you had exceeded your 
maximum allowance amount. 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 April 24, 2019. Therefore, we decided that the Plan does not have to pay for a complete maxillary and mandibular denture 
(D5110/D5120) provided on February 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a self-administered covid test provided on February 04, 
2023. 
 
You asked the Plan to pay for a self-administered covid test. You say that you thought that this test would 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 a self-administered 
covid test provided on February 04, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 reader. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 reader. You say that you need the Freestyle Libre 2 
reader because your sugar levels keep dropping. The Plan denied your request. The Plan says you do not meet 
Medicare criteria. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a Freestyle libre 2 reader. Our physician 
reviewer found that we are not told of blood sugars less than 54 with symptoms nor of insulin uses so criteria 
for coverage are not met.  
 
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 Freestyle Libre 2 reader have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Freestyle Libre 2 reader.