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

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140), pulp 
vitality tests (D0460) and endodontic therapy, molar tooth (excluding final restoration) (D3330) provided on 
June 29, 2020. 
 
You asked the Plan to pay for limited oral evaluation, pulp vitality tests and endodontic therapy. You say that 
you were unaware you exceeded your maximum benefit. The Plan denied your request. The Plan says after the 
annual maximum of $2000 is exhausted, any remaining charges are your responsibility. 
 
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 pay for limited 
oral evaluation - problem focused (D0140), pulp vitality tests (D0460) and endodontic therapy, molar tooth 
(excluding final restoration) (D3330) provided on June 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and vision exam (92083, 99213) provided on 
July 24, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and vision exam. You say that you believe you do not need a 
referral to seek care from other providers. The Plan denied your request. The Plan says prior authorization was 
not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 routine vision provider contracted with the Plan. 
 
We looked at the file and the Plan's rules. The services in this claim were obtained from an OON provider and 
were not approved in advance. Based on this information, we decided that the Plan's rules for coverage of the 
office visit and vision exam have not been met. Therefore, we decided that the Plan does not have to pay for the 
office visit and vision exam (92083, 99213) provided on July 24, 2020, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on June 10, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering 
physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the 
drug testing services provided on June 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical x-ray (D0220) provided on September 10, 
2020. 
 
You asked the Plan to pay for the dental service. You say that your husband does not have any back teeth and 
therefore bitewing x-rays are not an option. The Plan denied your request. The Plan says periapical x-rays are 
not listed as a covered service. 
 
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 pay for the 
periapical x-ray (D0220) provided on September 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on August 21, 2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
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 did not pre-approve the 
physician's services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on August 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a federally qualified health center (FQHC) telehealth visit 
(G2025) provided on May 7, 2020. 
 
You asked the Plan to pay for a FQHC telehealth visit. You say that this was billed correctly. The Plan denied 
your request. The Plan says this claim requires additional codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. FQHC qualifying visits must be reported with 3 
HCPCS/CPT codes. 
 
We find that this claim cannot be paid as billed. Specifically, telehealth distant site services furnished between 
January 27, 2020, and June 30, 2020 that are also FQHC qualifying visits require additional codes to be 
reported with G2025. Based on this information, we decided that Medicare rules for coverage of a FQHC 
telehealth visit have not been met. Therefore, we decided that the Plan does not have to pay for a federally 
qualified health center (FQHC) telehealth visit (G2025) provided on May 7, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an echocardiograph provided on March 
26, 2020. 
 
You asked the Plan to waive the coinsurance for an echocardiograph. You say that you were told that the test 
was preventative and you would not owe anything. The Plan denied your request. The Plan says the claims 
were processed correctly and you are being charged the correct amount. 
 
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 diagnostic procedures and tests. 
 
You received an echocardiograph on March 26, 2020. An echocardiograph is considered a diagnostic 
procedure and is not preventative. Therefore, you are responsible to pay your share of the cost-sharing charges. 
The allowed amount is $541.64 and 20% of that is $108.33.   
 
You have been asked to pay the total coinsurance amount of $108.33 for an echocardiograph. An 
echocardiograph falls within the outpatient diagnostic tests and therapeutic services and supplies benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the coinsurance for an echocardiograph provided on March 26, 
2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an echocardiograph provided on July 24, 
2020. 
 
You asked the Plan to waive the copayment for an echocardiograph. You say that you should only owe a $40 
copayment for specialist services. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct amount. 
 
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 $50 
copayment for diagnostic procedures and tests.  
 
You have been asked to pay a $50 copayment for an echocardiograph. An echocardiograph falls within the 
outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for an echocardiograph provided on July 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth distant site service (G2025) provided on June 
15, 2020. 
 
You asked the Plan to pay for the telehealth distant site service. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says Medicare rules for payment of 
this service have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for telehealth distant site services furnished 
between January 27, 2020, and June 30, 2020 that are also FQHC qualifying visits, you must report 3 
HCPCS/CPT codes. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the telehealth distant site service have not been met. Specifically, the claim does not include the 
 
 
three required CPT codes and modifiers for the distant site service. Therefore, we decided that the Plan does 
not have to pay for the telehealth distant site service (G2025) provided on June 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves, and the wrist hand 
orthoses provided on July 21, 2020. 
 
You asked the Plan to pay for the knee orthoses (L1851) and suspension sleeves (L2397), and the wrist hand 
orthoses (L3916). You say that the orthoses were medically necessary. The Plan denied your request. The Plan 
says the orthoses are not supported in the medical records received. 
 
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 pay for the knee orthoses (L1851) and suspension 
sleeves (L2397), and the wrist hand orthoses (L3916). Our reviewer says that the orthoses are not medically 
necessary. Our physician reviewer found the enrollee's chief complaints were pain located in knee left, knee 
right, and pain located in wrist left, wrist right, documented in 2 separate notes on the same date of service. 
The documentation in the case file does not support that the requested knee orthoses and sleeves were 
medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established 
by the LCD. There is insufficient documentation of an examination of the enrollee, and there is insufficient 
credible objective documentation of joint laxity. 
 
The item coded L2397 (sleeve) is not separately payable when the base item is not covered. The documentation 
in the case file does not support that the requested wrist/hand orthoses were medically reasonable and 
necessary for the enrollee in this case. An appropriate history and a physical examination of the wrists would 
reasonably be required to adequately assess whether the wrist/hand orthoses were medically reasonable and 
necessary. The documentation does not support that the wrist/hand orthoses were medically reasonable and 
necessary in this case, as there is insufficient documentation of a credible physical examination of the wrists. 
 
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 knee orthoses (L1851) and suspension sleeves (L2397), and the wrist hand 
orthoses (L3916) have not been met. Therefore, we decided that the Plan does not have to pay for the knee 
orthoses and suspension sleeves, and the wrist hand orthoses provided on July 21, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a transthoracic echocardiogram. 
 
You asked the Plan to pre-approve a transthoracic echocardiogram. You say that the requested transthoracic 
echocardiogram is medically necessary. The Plan denied your request. The Plan says that the requested 
transthoracic echocardiogram is not medically necessary. 
 
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 a transthoracic echocardiogram. Our 
reviewer says that the requested transthoracic echocardiogram is medically necessary. Our physician reviewer 
found the enrollee has known severe ischemic heart disease, status post coronary artery bypass graft x 4, newly 
progressive dyspnea with exertion and angina type left arm pain. He has not had a reassessment of his LV 
function in 8 years. Given the underlying known severe CAD and newly progressive dyspnea symptoms, a 
reassessment of his LV function using thoracic echocardiography is indicated. Transthoracic echocardiography 
is medically necessary and appropriate in this clinical situation, is in accordance with current AHA/ACC 
appropriate use guidelines, and clearly meets the CMS criteria for this study. 
 
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 transthoracic echocardiogram have been met. Therefore, we decided that the 
Plan has to pre-approve a transthoracic echocardiogram.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neurological testing (96116, 96132, 96133, 96138, 96139) 
provided from January 17, 2020, to January 23, 2020. 
 
You asked the Plan to pay for neurological testing. You say that these codes are supported in the record. The 
Plan denied your request. The Plan says these codes are not documented. 
 
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 96116 is neurobehavioral status exam (clinical 
assessment of thinking, reasoning and judgment, [e.g., acquired knowledge, attention, language, memory, 
planning and problem solving, and visual spatial abilities]), by physician or other qualified health care 
professional, both face-to-face time with the patient and time interpreting test results and preparing the report; 
first hour. The definition of 96132 is neuropsychological testing evaluation services by physician or other 
qualified health care professional, including integration of patient data, interpretation of standardized test 
results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to 
the patient, family member(s) or caregiver(s), when performed; first hour. The definition of 96133 is 
neuropsychological testing evaluation services by physician or other qualified health care professional, 
including integration of patient data, interpretation of standardized test results and clinical data, clinical 
decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or 
caregiver(s), when performed; each additional hour (List separately in addition to code for primary procedure). 
The definition of 96138 is psychological or neuropsychological test administration and scoring by technician, 
two or more tests, any method; first 30 minutes. The definition of 96139 is psychological or 
neuropsychological test administration and scoring by technician, two or more tests, any method; each 
additional 30 minutes (List separately in addition to code for primary procedure). 
 
 
 
 
 
We find that CPT codes 96116, 96132, 96133, 96138, and 96139 are not supported in the medical record. 
Specifically, these are time-based codes. The time spent on these services is not documented in the submitted 
medical records. Without this information, these codes cannot be verified. Based on this information, we 
decided that Medicare rules for coverage of neurological testing have not been met. Therefore, we decided that 
the Plan does not have to pay for neurological testing (96116, 96132, 96133, 96138, 96139) provided from 
January 17, 2020, to January 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for retainer crown (D6740) and pontic (D6245) provided on 
May 11, 2020. 
 
You asked the Plan to pay for crown and pontic. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the services rendered are not covered benefits of your Plan. 
 
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 pay for retainer 
crown (D6740) and pontic (D6245) provided on May 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PVA, including cavity creation (fracture reduction and 
bone biopsy included when performed) using mechanical device (e.g., kyphoplasty), 1 vertebral body, 
unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar (CPT Code 22514). 
 
You asked the Plan to pre-approve the PVA. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not 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 PVA. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation this is a new fracture that is less than 6 weeks old. Criteria not met. 
Recent literature shows kyphoplasty is not more effective than sham treatment. 
 
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 PVA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve PVA, including cavity creation (fracture reduction and bone biopsy included when performed) 
using mechanical device (e.g., kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of 
all imaging guidance; lumbar (CPT Code 22514).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider from January 30, 2020, to February 27, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network 
services are 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider 
from January 30, 2020, to February 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided by May 13, 2020, to June 3, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that the member's primary care physician did not refer these services. 
 
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 has network providers 
available who can provide 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 physician services provided by May 13, 2020, to 
June 3, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 29, 2019, through 
September 12, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the 
laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation 
and/or claim history indicates that the specimen was obtained in an On Campus-Outpatient Hospital setting 
POS 22. 
 
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare 
Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting 
where the beneficiary receives the face to-face service. 
 
 
 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with POS code 81 
indicating the specimen was collected in the laboratory. However, the record indicates that the specimen was 
collected in an outpatient hospital setting. Therefore, we decided that the Plan does not have to pay for 
laboratory services provided on August 29, 2019, through September 12, 2019.