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

 
We decided that the Plan does not have to pay for laboratory services (procedure code 87481, 87640, 87798) 
rendered on September 1, 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 the denied codes remain 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 the denied codes is: 
 
CPT 87481: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe technique 
 
CPT 87640: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified probe technique 
 
CPT 87798: 
 
Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, 
each organism 
 
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 laboratory report does not 
include documentation to support that these procedures were distinct procedural services from the panel code. 
The codes and modifier 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services (procedure code 87481, 87640, 87798) rendered on September 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on September 11, 2023. 
 
You asked the Plan to pay for eye refraction. You say that you were referred to this physician who deemed the 
refraction to be part of the evaluation process. The Plan denied your request. The Plan says this provider is not 
part of the Plan's routine vision network; therefore, the eye refraction is not covered when performed by this 
provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when obtained from a Plan routine vision care network provider. 
 
We looked at the file and the Plan's rules. This eye refraction was not obtained from a Plan routine vision care 
network provider. Based on this information, we decided that the Plan's rules for coverage of eye refraction 
have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on 
September 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam CT capture and interpretation with limited 
field of view - less than one whole jaw (D0364). 
 
You asked the Plan to pre-approve the cone beam CT capture and interpretation. You say that you disagree 
with the denial of the dental services. The Plan denied your request. The Plan says the cone beam CT capture 
and interpretation D0364 is not covered in your dental benefit. If covered, D0364 would be listed on page 8 of 
your Dental Benefits Details guide. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
cone beam CT capture and interpretation with limited field of view - less than one whole jaw (D0364).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing billed for date of service July 3, 2023. 
 
You asked the Plan to pay for the lab testing. You say that the treatment sought was medically necessary. The 
Plan denied your request. The Plan says that a unique identifier was not billed. 
 
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. 
 
We looked at the file and the rules. We find that codes 81162, 81218, and 81209 were denied based on 
guidelines found in Local Coverage Determination, LCD L38972. The Plan did not provide any rationale to 
deny based on these guidelines. Additionally, the LCD does not have jurisdiction where the services were 
provided. The Plan denied code 81272 as a unique identifier, required for molecular diagnostic tests, was not 
billed on the claim. The Plan also denied code 81272 as the TERC and BLM genes are excluded from 
coverage. The Local Coverage Articles, A57526 and A55113, the Plan used to substantiate their denial do not 
have jurisdiction where the services were provided. Additionally, there is no documentation to show that the 
testing of code 81272 includes the testing of the TERC and BLM genes. The Plan has not made reasonable and 
diligent efforts to gather and forward to us information regarding their decision to deny your request. 
Therefore, we decided that the Plan has to pay for the lab testing billed for date of service July 3, 2023.  
 
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 waive the copayment for the inpatient hospital stay provided on 
September 02, 2022, to September 27, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. 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 $305 
copayment for inpatient hospital care. 
 
You have been asked to pay a $305 copayment for the inpatient hospital stay. This item/service falls within the 
inpatient hospital care 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 are responsible for a $1,830 copay ($305 x 6 days). You were not charged for days 7-
25. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital stay 
provided on September 02, 2022, to September 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit evaluation nail debridement procedure provided 
on August 15, 2023. 
 
You asked the Plan to pay for a home visit evaluation nail debridement procedure. 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 a home visit evaluation 
nail debridement procedure provided on August 15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cervical disc replacement (22856 x2). 
 
You asked the Plan to pre-approve cervical disc replacement. 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 cervical disc replacement 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 cervical disc replacement. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the enrollee has a body mass 
index (BMI) greater than 40 which is a contraindication to the surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cervical disc replacement have not been met. Therefore, we decided that the 
Plan does not have to pre-approve cervical disc replacement (22856 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat elevator (E2300), power tilt/recline (E1007), 
power legrests (E1012), and upgraded electronics (E2311, E2377). 
 
You asked the Plan to pre-approve the multiple power options and upgraded electronics. You say that medical 
records have been provided to support the medical necessity. The Plan denied your request. The Plan says there 
is no medical need for the requested multiple power options. 
 
The Plan follows Medicare rules. Medicare rules say that multiple power options may be covered 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 multiple power options and upgraded 
electronics. Our reviewer says that the requested power options and upgraded electronics are not medically 
necessary. Our physician reviewer found the provided records do not support that the enrollee has high risk for 
skin breakdown, uses a catheter intermittently, has spasticity or requires an alternative means of managing 
power drive. Therefore, the reviewer found that the requested power options and upgraded electronics are not 
medically reasonable or 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 multiple power options and upgraded electronics have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a seat elevator (E2300), power tilt/recline (E1007), 
power legrests (E1012), and upgraded electronics (E2311, E2377).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital inpatient or observation care (99232) 
provided September 5, 2023. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the diagnosis codes should not be reported together which is based on the Excludes1 Notes 
instructions in the ICD-10-CM Official Guidelines for Coding and Reporting. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. The billed service 99232 was denied 
because the diagnosis codes associated to H81.10 and R42, should not be reported together. The billed service 
has been denied because it was reported with one or more diagnosis code pairs that are subject to an Excludes1 
note. Therefore, we decided that the Plan does not have to pay for the subsequent hospital inpatient or 
observation care (99232) provided September 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on March 28, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the diagnosis code at 
issue is not appropriate as a primary diagnosis.  
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code J91.0. This code is 
not an appropriate primary diagnosis as the code has a Code first note indicating to code the underlying 
condition first. Based on this information, we decided that Medicare rules for payment of this claim have not 
been met. Therefore, we decided that the Plan does not have to pay for the services provided on March 28, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve ophthalmology services. You say that you are appealing the denial. The 
Plan denied your request. The Plan says that their original decision to deny coverage was correct. 
 
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 
ophthalmology services to be provided by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97112-GP billed for date of service May 9, 
2022. 
 
You asked the Plan to pay for procedure code 97112. You say that this claim should be paid. The Plan denied 
your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on August 3, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for procedure code 97112 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 97112-GP billed for date of 
service May 9, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from July 21, 2023, to July 
24, 2023. 
 
You asked the Plan to pay for the home health services. You say that you have provided medical records to 
show the necessity of these services. The Plan denied your request. The Plan says you billed this claim with an 
incorrect Type of Bill code. 
 
The Plan must follow Medicare rules. Medicare rules say that the Type of Bill code is a 4-digit alphanumeric 
code that gives two pieces of information. The first three digits indicate the base type of bill. The fourth digit 
indicates the sequence of this bill in this particular period of care. The acceptable 4th digit options are as follows: 7 (to indicate a replacement of a prior claim); 8 (to indicate a void or cancel of a prior claim); and 9 (a 
final claim).  
 
Based on this rule, you should have billed this home health claim with Type of Bill code 0329. Instead, you 
billed with code 0323, which is incorrect. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to 
pay for home health services provided from July 21, 2023, to July 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on July 27, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
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 pay for the pneumatic compression device provided on July 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88108 billed for date of service May 3, 2023. 
 
You asked the Plan to pay for procedure code 88108. The Plan denied your request. The Plan says payment for 
code 88108 is bundled into payment for code 88187.  
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 88108 
is a column II code to column I code 88187. 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 88108 billed for date of service May 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99204 and 99199 billed for date of service 
May 19, 2023. 
 
You asked the Plan to pay for procedure codes 99204 and 99199. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says procedure code 99199 is considered bundled and not 
separately payable. The Plan also says that procedure code 99204 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 procedure code. 
 
 We find that procedure code 99199 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99199 is not separately payable. We find that CPT code 99204 is not supported in the medical 
record. Specifically, the documentation shows that you are a current patient of this provider. This means code 
99204 is not supported. Based on this information, we decided that Medicare rules for coverage of procedure 
codes 99204 and 99199 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 99204 and 99199 billed for date of service May 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided from September 18, 2023, to 
September 25, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for chiropractic services. You say that you are appealing the denial. The Plan denied 
your request. The Plan says that their original decision to deny payment was correct. 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for chiropractic services provided from September 18, 
2023, to September 25, 2023, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 18, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on August 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, and the laboratory services provided on 
August 18, 2023. 
 
You asked the Plan to pay for an office visit, and 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 an office visit, and the 
laboratory services provided on August 18, 2023.