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

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) and the 
rechargeable station (V5267) purchased on January 27, 2023. 
 
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 hearing aids are not payable 
as they were rendered by an out-of-network provider. Additionally, a rechargeable station is not covered.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.   
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plan's contract says that hearing aids are covered 
only when purchased from the Plan's select hearing aid provider. The hearing aids in this case were purchased 
from an out-of-network provider. Additionally, there is no coverage for additional costs for hearing aid 
rechargeability. Therefore, we decided that the Plan does not have to issue reimbursement for the hearing aids 
(V5261) and the rechargeable station (V5267) purchased on January 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy services (D3320) provided on January 
11, 2023, to January 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. 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 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 the requested item or service was exhausted on date of service January 18, 2023. 
Therefore, we decided that the Plan does not have to pay for endodontic therapy services (D3320) provided on 
January 11, 2023, to January 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology services provided on October 16, 
2020. 
 
You asked the Plan to pay for the surgical pathology services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the claim needs to be processed by the enrollee's primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the surgical pathology services until the primary insurer has denied the claim for these services.  Therefore, 
we decided that the Plan does not have to pay for the surgical pathology services provided on October 16, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 5, 2022, billed 
with code 81272. 
 
You asked the Plan to pay for the genetic testing billed. You say that this was medically necessary testing. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim.  
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
December 5, 2022, billed with code 81272.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve rehabilitation services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve rehabilitation services. You say that the provider is the only pain 
management doctor that will see you. The Plan denied your request. The Plan says this is available in-network. 
 
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 
rehabilitation services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation. 
 
You asked the Plan to pre-approve percutaneous vertebral augmentation. 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 PVP and PVA will be considered reasonable and 
necessary for osteoporotic conditions when certain 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 percutaneous vertebral augmentation. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found there are no 
imaging studies showing an acute fracture that is less than 6-12 weeks old. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous vertebral augmentation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve percutaneous vertebral augmentation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing. 
 
You asked the Plan to pre-approve neuropsychological testing. You say that you have been experiencing 
memory loss and word/name recall problems over the past five to seven years, and it has gotten worse. You 
believe that neuropsychological testing is medically necessary, and you were denied unfairly. The Plan denied 
your request. The Plan says you do not meet the above criteria because neuropsychiatry testing for a patient 
with an established diagnosis of dementia that will not impact your medical management is not considered to 
be medically necessary at this time. 
 
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 neuropsychological testing. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation shows you claim to have memory impairment 
documented and word/name recall for the past 5 to 7 years. Utilizing the criteria for neuropsychological testing 
and LCD L35101, this testing is intended to diagnose and characterize the neurocognitive effects of medical 
disorders that impinge directly on or indirectly on the brain including detection of neurologic disease based on 
quantitative assessment of neurocognitive abilities, differential diagnosis between psychogenic and neurogenic 
syndromes, delineation of neurocognitive effects of central nervous system disorders, neurocognitive 
monitoring of recovery or progression of central nervous system disorders or assessment of neurocognitive 
function for the formulation of rehabilitation and/or management strategies among individuals with 
neuropsychiatric disorders. The request for neuropsychological testing is not medically necessary or reasonable 
as information presented is sufficient for the decision-making process for your treatment. It is unclear how this 
testing would impact your treatment significantly. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neuropsychological testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service December 
28, 2022. 
 
You asked the Plan to pay for procedure code 99053. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 99053 is considered bundled 
and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service December 28, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on September 26, 2022, billed
with codes 81314, 81345, and 81272.

You asked the Plan to pay for the genetic testing billed. You say that this testing should be paid due to medical
necessity. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on
the claim.

The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or
proprietary laboratory analysis code.

We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on
September 26, 2022, billed with codes 81314, 81345, and 81272.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-invasive physiological studies, Duplex scan of the
upper extremities, spirometry, electrocardiogram (EKG), transthoracic echocardiogram (TTE), and a computed
tomography (CT) scan of the thorax from an out-of-network (OON) provider.

You asked the Plan to pre-approve these services. You say that you need the testing prior to surgery and it can't
be done at St. Ann's. The Plan denied your request. The Plan says the services are available from network
providers. 

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. The Plan confirmed that there is an innetwork
hospital that can provide the requested testing. 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 noninvasive
physiological studies, Duplex scan of the upper extremities, spirometry, electrocardiogram (EKG),
transthoracic echocardiogram (TTE), and a computed tomography (CT) scan of the thorax from an out-ofnetwork
(OON) provider.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pre-approve additional routine transportation.

You asked the Plan to pre-approve the additional trips. You say that this is needed for upcoming doctor's appointments. The Plan denied your request. The Plan says that you have exhausted the benefit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers additional routine transportation for up to 12 one-way trips to Plan' approved locations

We looked at your request, the records in the case file, and the rules. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. There is no evidence showing your benefit for the requested item or service was previously exhausted. Based on this information, we decided that the Plan's rules for coverage of additional routine transportation have been met. Therefore, we decided that the Plan has to pre-approve additional routine transportation.

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services rendered from April 1,
2022, to April 9, 2022.

You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your
request. The Plan says the provider has reported skilled services with the incorrect PDPM Health Insurance
Prospective Payment System (HIPPS) Score.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

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 in this case, the documentation
doesn't support the correct PDPM was submitted by the skilled nursing facility. The documentation available
for review that pertains to the appropriate look-back period does not support that the enrollee received a
mechanical diet. Additionally, the documentation doesn't support the coded nursing and physical therapy
functional codes. The 1st, 2nd and 3nd, alphanumeric character in the PDPM were not correct. The partial
adjustment to PDPM LDQE1 was appropriate.

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 skilled nursing facility (SNF) services rendered from April 1, 2022, to April 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on
September 29, 2022.

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 the documents do not support this level of care.

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 99223 is "Initial hospital care, per day, for the evaluation
and management of a patient, which requires these 3 key components: A comprehensive history; A
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor
or unit."

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 in this case, the documentation
doesn't support the CPT code 99223. The documentation available for review does not support the encounter
contained the 3 key components required to support the CPT code 99223.

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 initial hospital care (procedure code 99223) rendered on September 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with the requested provider, an 
Obstetrics/Gynecology (OB/GYN) specialist. 
 
You asked the Plan to pre-approve an office visit with an OB/GYN specialist.. You say that the services are 
necessary. The Plan denied your request. The Plan says your primary care physician has not provided the 
necessary referral. Therefore, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We looked the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage 
of an office visit with an OB/GYN specialist. have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an office visit with the requested provider, an Obstetrics/Gynecology (OB/GYN) specialist.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 14 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy visits. You say that you fell and now have a hip and knee 
injury. The Plan denied your request. The Plan says 14 additional physical therapy visits are not medically 
necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found that you have an effective set of exercises and can continue 
with a home exercise program. The Plan's allotment of visits is reasonable as you are doing well with a 
repetitive program. Therefore, continued input of a skilled therapist beyond the additional visits is not 
medically 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 physical therapy visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 14 additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653 and 87798 billed for date of 
service November 23, 2022. 
 
You asked the Plan to pay for procedure codes 87481, 87653 and 87798. You say that these services are 
supported in the medical records. The Plan denied your request. The Plan says the payment for these services is 
included in the payment for code 87801. 
 
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 87481, 87653 and 87798 are column II codes to column I code 
87801. Codes 87481 and 87653 have not been billed with an appropriate modifier to bypass the edit. Based on 
the claim submitted, Medicare billing criteria have not been met for codes 87481 and 87653. However, code 
87798 was billed with a modifier.  
 
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 87798. Our reviewer says that modifier XU 
is not supported with code 87798. Our reviewer found the records do not support that code 87798 is separately 
identifiable from 87801. The not otherwise specified organisms of code 87798 are included in the multiple 
organisms reported with 87801. 
 
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 codes 87481, 87653 and 87798 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87481, 87653 and 87798 billed for date of 
service November 23, 2022.