Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic office visit (99202), electrical stimulation 
(G0283), electrodes (A4556), and the application of hot or cold packs (97010) provided from  February 6, 
2020, to February 13, 2020. 
 
You asked the Plan to pay for a chiropractic office visit, electrical stimulation, electrodes, and the application 
of hot or cold packs. You say that these services should be covered. The Plan denied your request. The Plan 
says these services are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for a chiropractic office visit (99202), electrical stimulation (G0283), electrodes 
(A4556), and the application of hot or cold packs (97010) provided from  February 6, 2020, to February 13, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transluminal dilation of aqueous outflow cana services 
coded 66174, the goniotomy services coded 65820, and the extracapsular cataract removal with insertion of 
intraocular lens prosthesis services coded 66984 provided on January 6, 2020. 
 
You asked the Plan to pay for the transluminal dilation of aqueous outflow cana services, the goniotomy 
services, and the extracapsular cataract removal with insertion of intraocular lens prosthesis services. You say 
that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services 
billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 66174, 65820, and 66984 are not supported in the medical record. Specifically, the 
documentation submitted did not include a detailed procedure note for the billed date of service for 
transluminal dilation of aqueous outflow canal; without retention of device or stent; therefore, code 66174 
cannot be verified. 
The documentation submitted did not include a detailed procedure note for the billed date of service for 
goniotomy; without retention of device or stent; therefore, code 65820 cannot be verified. Lastly, the 
documentation submitted did not include a detailed procedure note for the billed date of service for 
extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or 
mechanical technique; without retention of device or stent; therefore, code 66984 cannot be verified. 
Based on this information, we decided that Medicare rules for coverage of the transluminal dilation of aqueous 
outflow cana services, the goniotomy services, and the extracapsular cataract removal with insertion of 
intraocular lens prosthesis services have not been met. Therefore, we decided that the Plan does not have to pay 
for the transluminal dilation of aqueous outflow cana services coded 66174, the goniotomy services coded 
65820, and the extracapsular cataract removal with insertion of intraocular lens prosthesis services coded 
66984 provided on January 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 19, 2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization.  
 
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 March 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397, 
L2385) provided to the enrollee on April 12, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says there is no itemized billing/shipping invoice to verify the services billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a proof of delivery to support medical necessity for the supplies provided in this 
case. There is no itemized billing/shipping invoice to verify the services billed. 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 a knee orthosis with suspension sleeve (L1851, L2397, L2385) provided to the 
enrollee on April 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compressor and segmental pneumatic 
appliance provided on March 19, 2020. 
 
You asked the Plan to pay for the pneumatic compressor and segmental pneumatic appliance. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation 
is missing required information. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file 
shows that the documentation submitted did not include a valid physician order for the billed date of service. 
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 pneumatic compressor and segmental 
pneumatic appliance provided on March 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the chemodenervation procedure you had 
on May 18, 2020. 
 
You asked the Plan to waive the copayment for the chemodenervation procedure. You say that since this 
procedure was done in an office, you should only have to pay a $5 copayment. The Plan denied your request. 
The Plan says you were charged this copayment 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 $300 
copayment for outpatient surgical services.  
 
You have been asked to pay a $300 copayment for the chemodenervation procedure. The chemodenervation 
procedure is an outpatient surgical procedure.  You did not have this procedure at an ambulatory surgical 
center.  Your Evidence of Coverage explicitly states that outpatient surgery services performed in a setting 
other than an ambulatory surgical center are subject to a $300 copayment. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for the chemodenervation procedure you had on May 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care (99291) provided on March 28, 2020. 
 
You asked the Plan to pay for critical care. You say that this is documented in the records. The Plan denied 
your request. The Plan says this code 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 CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the specific amount of time 
spent on this service is not documented in the record. Based on this information, we decided that Medicare 
rules for coverage of critical care have not been met. Therefore, we decided that the Plan does not have to pay 
for critical care (99291) provided on March 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe occlusal guard(D9944) provided on March 3, 2020.You asked the Plan to pay forthe occlusal guard. You say that you were experiencing discomfort caused from your grinding.The Plan denied your request. The Plan says this service is not a covered benefit.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 forthe occlusal guard (D9944) provided on March 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 2, 2020 by a non-
participating provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by a non-participating provider without prior authorization. 
 
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 the medical services provided on July 2, 2020 by a 
non-participating provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care provided on October 23, 2019. 
 
You asked the Plan to pay for the subsequent hospital care. You say that The Plan denied your request. The 
Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of 
Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The 
Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and 
to know proper billing procedures for a Medicare Advantage member on hospice. 
 
 
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 date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent hospital care provided on October 23, 2019.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for physical therapy services (97530) provided on February 20, 2020. 
 
You asked the Plan to pay for the physical therapy services. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says that this claim has previously been 
processed and paid. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has failed to forward evidence that any number of units of 
this service were previously processed and paid for the billed date of service. It is the burden of the Medicare 
Health Plan to substantiate the denial with evidence. The denial is not substantiated and we must find in your 
favor. Therefore, we decided that the Plan has to pay for physical therapy services (97530) provided on 
February 20, 2020.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CGM (K0553) provided on January 27, 2020, through 
April 30, 2020. 
 
You asked the Plan to pay for the CGM. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the documentation submitted did not include an 
itemized shipping/billing invoice to indicate the specific supplies or proof of delivery. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of deliveryfor the supplies provided in this case. Specifically, the 
record does not include a delivery ticket or an itemized billing/shipping invoice. 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 a CGM (K0553) provided on January 27, 2020, through April 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
January 6, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation. The Plan denied your request. The Plan says 
this service exceeds the frequency limitation in your benefit 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, comprehensive oral evaluation 
(D0150) is limited to one procedure every three plan years. The record shows that you received a 
comprehensive oral evaluation (D0150) on January 21, 2020, and your comprehensive oral evaluation (D0150) 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive 
oral evaluation (D0150) provided on January 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for an X-Ray examination and outpatient 
surgical services provided from October 31, 2019, to January 3, 2020. 
 
You asked the Plan to waive the cost-sharing for X-Ray and outpatient surgery. You say that you cannot afford 
these amounts. The Plan denied your request. The Plan says the cost-sharing amounts you are being charged 
are correct. 
 
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 $40 
copayment for X-Ray, $400 copayment for outpatient surgery in 2019, and $375 copayment for outpatient 
surgery in 2020. For some of these services, you have been asked to pay the allowed amount because it is less 
than the applicable copayment amount. A summary of your cost-sharing responsibilities is on the next page. 
  
 
Date of Service 
Service 
Provided 
Allowed 
Amount 
Cost-Share Per 
Contract 
Your Cost-Share 
Responsibility 
October 31, 2019 
X-Ray 
Exam 
$17.90 $40 copayment $17.90 
December 6, 2019 
Outpatient 
Surgery 
$889.51 $400 copayment $400 
December 20, 2019 
Outpatient 
Surgery 
$10.48 $400 copayment $10.48 
January 3, 2020 
Outpatient 
Surgery 
$849.47 $375 copayment $375 
Total    $803.38 
 
Your total copayment obligation is therefore $803.38. 
 
You have been asked to pay up to $40 copayment for X-Ray, $400 copayment for outpatient surgery in 2019, 
and $375 copayment for outpatient surgery in 2020. X-Ray and outpatient surgery fall within the "Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies" and "Outpatient Surgery, Including Services Provided 
at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit categories. 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-sharing for an X-Ray examination and outpatient surgical services provided 
from October 31, 2019, to January 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for metatarsal fracture treatment (28485) and a prosthetic 
implant (L8699) provided on August 21, 2019. 
 
You asked the Plan to pay for the fracture treatment and implant. You say that you would like reconsideration 
because the additional units of these codes were not paid. The Plan denied your request. The Plan says a 
modifier is necessary to show that these services are separate from the previously processed and paid codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 28485 and L8699 is not supported in the record. Specifically, these codes require a 
modifier to show that they are separate from the codes that have already been processed and paid by the Plan. 
Based on this information, we decided that Medicare rules for coverage of the fracture treatment and implant 
have not been met. Therefore, we decided that the Plan does not have to pay for metatarsal fracture treatment 
(28485) and a prosthetic implant (L8699) provided on August 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency treatment of dental pain (D9110) and the 
extraction (D7140) provided from June 9, 2020, to June 17, 2020. 
 
You asked the Plan to pay for the dental services. You say that you fell and broke your tooth. You say that you 
received a check after your first visit. You say that the services should be fully covered. The Plan denied your 
request. The Plan says emergency treatment of dental pain is not listed as a covered service. The Plan says that 
extractions are not listed as a covered service. The Plan also says any services not listed are not covered. 
 
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 dental services you received are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
emergency treatment of dental pain (D9110) and the extraction (D7140) provided from June 9, 2020, to June 
17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the alveoloplasty (41874 x 4) provided on December 10, 
2019. 
 
You asked the Plan to pay for the dental services. You say that procedure 41874 is payable per Medicare 
guidelines. The Plan denied your request. The Plan says the services that the enrollee received are dental in 
nature. The Plan says that dental services are not payable under the enrollee's medical plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
Although the enrollee's plan offers a dental benefit that exceeds Medicare, the services you are asking the Plan 
to pay for involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures 
directly supporting the enrollee's teeth. The services that the enrollee received are dental services that are not 
covered or paid for by Medicare. The record shows that the Plan's Dental Rider paid the annual allowance of 
$150. Therefore, we decided that the Plan does not have to pay any additional amount for the alveoloplasty 
(41874 x 4) provided on December 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in-network rate for the periapical x-ray (D0220), the 
extraction (D7140), and the placement of an intra-socket biological dressing (D7922) provided on June 1, 
2020. 
 
You asked the Plan to pay the in-network rate for the dental services. You say that you were not able to see an 
in-network provider office because offices were closed due to COVID-19. You say that you saw this provider 
as an emergency patient. You also say that you needed the tooth pulled right away. The Plan denied your 
request. The Plan says the provider in this case is not a network provider. The Plan says services that you 
receive out of network are paid according to a maximum allowable fee schedule.  
 
The cost share is a contractual obligation of the plan and cannot be waived. The cost share was applied 
correctly per your plan benefits and is 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 and the x-ray and extraction are listed 
as covered services, you may pay more when you receive these services out of network. The cost share is a 
contractual obligation of the plan and cannot be waived. The record shows that the cost share was applied 
correctly per your plan benefits and is your responsibility.  
 
 
 
CPT Code Billed 
Amount 
Allowed 
Amount 
Cost Share Plan Paid OON Cost 
Share 
Your 
Responsibility 
D0220 $35 $11 $0 $11 $24 $24 
D7140 $171 $56 $28 $28 $115 $143 
D7922 $46 $0 $0 $0 $46 $46 
TOTAL:    $39 $185 $213 
 
Additionally, the placement of an intra-socket biological dress is not a covered service. Therefore, we decided 
that the Plan does not have to pay the in-network rate for the periapical x-ray (D0220), the extraction (D7140), 
and the placement of an intra-socket biological dressing (D7922) provided on June 1, 2020.