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

 
We decided that the Plan does not have to pre-approve a maxillary complete denture (D5110) and mandibular 
complete denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee's dentures have been destroyed 
beyond repair and need to be replaced. 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 October 14, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary complete denture (D5110) and 
mandibular complete denture (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the right hip orthosis (L1686 and L2624) provided on April 
19, 2023. 
 
You asked the Plan to pay for the hip orthosis. You say that the item should be covered. The Plan denied your 
request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. There is no documentation indicating a face-to-face evaluation of the enrollee's hip. Nothing in the 
medical records indicates why a hip orthosis would be needed. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for the right hip orthosis (L1686 and L2624) provided on April 19, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 24, 2023. 
 You asked the Plan to pay for the office visit. You say that the services were not related to the enrollee's 
hospice diagnosis. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for an office visit provided on April 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied claim and that the services requested are medically necessary. 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 July 21, 2021. Therefore, 
we decided that the Plan does not have to pre-approve the dental services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 81433 for the Invitae BRCA 1/2 Panel provided on 
April 18, 2023. 
 
You asked the Plan to pay for code 81433. You say that this testing was medically necessary. The Plan denied 
your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of code 81433 have not been met. Therefore, 
we decided that the Plan does not have to pay for code 81433 for the Invitae BRCA 1/2 Panel provided on 
April 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93229 provided on August 2, 2022. 
 
You asked the Plan to pay for procedure code 93229. You say that the medical records support the billing of 
code 93229.  The Plan denied your request. The Plan says the medical records do not support the billing of 
code 93229.  
 
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 93229 is External mobile cardiovascular telemetry with 
electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of 
accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events 
transmitted to a remote attended surveillance center for up to 30 days; technical support for connection and 
patient instructions for use, attended surveillance, analysis and transmission of daily and emergent data reports as prescribed by a physician or other qualified health care professional. 
 
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 93229. Our reviewer says that the medical 
records do not support the billing of code 93229.  Our reviewer found there is no evidence that the ambulatory 
electrocardiogram (ECG) monitoring supports use of Mobile Cardiac Outpatient Telemetry (MCOT) monitor 
code 93229. In summary, there is insufficient documentation to support the MCOT monitor code 93229. 
 
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 93229 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 93229 provided on August 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 11, 2022, billed 
with codes 81177, 81178, 81179, 81180, 81181, 81182, 81185, 81189, 81343, 81344, 81401, 81403, 81403, 
81404, 81404, 81405 and 81406. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported in the medical record. 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 11, 2022, billed with codes 81177, 81178, 81179, 81180, 81181, 81182, 81185, 81189, 81343, 
81344, 81401, 81403, 81403, 81404, 81404, 81405 and 81406.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 21, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you are appealing the denied claim. The Plan denied 
your request. The Plan says the enrollee has no out of network benefits. 
 
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 an office visit provided on February 21, 2023, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cervical epidural steroid injection. 
 
  You asked the Plan to pre-approve the injection. You say that the enrollee had a problem with cervical 
degenerative disc disease and spondylosis causing chronic neck pain. You say that the problem has affected 
their activities of daily living, sleep, and quality of life. The Plan denied your request. The Plan says a cervical 
epidural steroid injection is not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that a 
cervical epidural steroid injection is not medically necessary. Our physician reviewer found that the LCD 
requires advance imaging of the neck to be documented before and epidural steroid injection. Therefore, the 
request is not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a cervical epidural steroid injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is the safest discharge plan, allowing 
the highest potential for the enrollee's recovery, preventing further deterioration and the best use of medical 
management. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for care in 
an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in the current acute care setting as provided 
by the Plan. The documentation does not support that LTACH services are medically appropriate at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 22, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration stating the claim 
was denied incorrectly. The Plan denied your request. The Plan says Medicare rules say that health Plans can 
require enrollees to get care 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 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 an office visit provided on February 22, 2023, by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T11 kyphoplasty surgery. 
 
You asked the Plan to pre-approve kyphoplasty. You say that the enrollee's surgery is urgent. The Plan denied 
your request. The Plan says there is insufficient documentation of reevaluation after a trial of non-surgical 
management, worsening pain, or radiographic progression despite non-surgical management. 
 
The Plan follows Medicare rules. Medicare rules state that kyphoplasty surgery is only covered if 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 kyphoplasty. Our reviewer says that the 
enrollee does not meet criteria for this kyphoplasty. Our physician reviewer found detailed documentation is 
not evident regarding an acute/subacute fracture at the T11 level. An office note from September 1, 2023 states 
the enrollee does not have a fracture at the T11 level. Magnetic resonance imaging (MRI) did show a fracture 
at the T11 level; however, notes it is similar to the plain film imaging from June 30, 2021. Moreover, there is 
MRI corroboration of retropulsion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve T11 kyphoplasty surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Light Emitting Diode (LED) light kit (K0108) and 
Colorado prep and assembly (A9900). 
 
You asked the Plan to pre-approve an LED light kit and Colorado prep and assembly. You say that you are 
submitting this appeal so the client can get the equipment/devices they need to help make their daily lives for 
the better. The Plan denied your request. The Plan says the LED light kit (K0108) is non-covered because it is 
not primarily medical in nature. The Plan also says the enrollee has been approved for a power wheelchair. No 
additional payment is allowed for labor charges. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. Medicare rules also say that reimbursement for the wheelchair codes includes all labor 
charges involved in the assembly of the wheelchair.  
 
The LED light kit does not serve a purpose that is primarily medical in nature. This item is available to the 
general public and would be helpful even to those who are not sick or injured. The record also show that the 
enrollee has been approved for a power wheelchair, which is why labor charges cannot be approved. Therefore, 
we decided that the Plan does not have to pre-approve a Light Emitting Diode (LED) light kit (K0108) and 
Colorado prep and assembly (A9900).
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve oncology (pan-cancer), analysis of minimal residual disease 
(MRD) from plasma (0340U). 
 
You asked the Plan to pre-approve diagnostic testing. You say that you are requesting reconsideration because 
it is medically necessary for you to know which staging formula you employ due to the size of the tumor and 
the fact that isolated tumor cells were found in four lymph nodes. The Plan denied your request. The Plan says 
that the request is not medically necessary because your records show you do not have Stage IIb or Stage III 
breast cancer, or that you are on immune checkpoint inhibitor therapy. 
 
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 diagnostic testing. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the stage is misdiagnosed in clinical documentation. In the setting of I+ it is likely that there is 
lymph node as documented in appeal. However, we agree that the documentation is not clear. As documented 
in notes the Stage would be 1B - Pathologic stage from January 17, 2023: Stage IB (pT3, pN0(i+)(sn), cM0, 
G2, ER+, PR+, HER2-, Oncotype DX score; However, the I+ likely suggests lymph node involvement 
justifying the testing. Therefore, the enrollee meets criteria for the requested testing.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of diagnostic testing have been met. Therefore, we decided that the Plan has to 
pre-approve oncology (pan-cancer), analysis of minimal residual disease (MRD) from plasma (0340U).  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for emergency care and an outpatient diagnostic 
test provided on March 2, 2023, to April 6, 2023. 
 
You asked the Plan to waive the cost share for emergency care and an outpatient diagnostic test. You say that 
you disagree with the cot share. 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 $110 
copayment for emergency care and a 20% coinsurance for outpatient diagnostic tests/Medicare-covered 
diagnostic tests.  You have been asked to pay a $110 copayment for emergency care and a 20% coinsurance for an outpatient 
diagnostic test. The total allowed amount for the diagnostic test is $4,751.96. You are being asked to pay 
$950.39 ($4,751.96 x 20% = $950.39). The total amount you are being asked to pay is $1,060.39 ($950.39 + 
$110 = $950.39). This item/service falls within the emergency care and outpatient diagnostic tests/Medicare-
covered diagnostic tests 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 cost share for emergency 
care and an outpatient diagnostic test provided on March 2, 2023, to April 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on June 9, 2023.  
 
You asked the Plan to pay for foot orthotics. You say that you would like reconsideration because the requested 
foot orthotics are medically necessary. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on June 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 1, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the lab services. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says the service was not authorized. 
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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 the laboratory services provided on March 1, 
2023, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic image (D0230) provided on April 
4, 2023. 
  
You asked the Plan to pay for the dental service. You say that you did not know you were able to have x-rays 
done once a year so you should not be held accountable for the amount to be paid. 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 the Plan paid for the intraoral radiographic image (D0220) on April 4, 2023; therefore, your benefit for 
the requested item or service was exhausted on the date of service of April 4, 2023. Therefore, we decided that 
the Plan does not have to pay for the intraoral radiographic image (D0230) provided on April 4, 2023.