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

 
We decided that the Plan does not have to pay for radiology services (CPT 75774) provided to the enrollee on 
November 7, 2019. 
 
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 records do not support that the service was performed more than once on the date of service, 
and the code was not billed to reflect the service was a repeat or separately identifiable service. 
 
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 75774 is "Diagnostic Radiology (Diagnostic Imaging) 
Procedures of the Aorta and Arteries. 
 
We asked our coding 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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found the 
procedure report does not support CPT +75774 with modifier 59 (Distinct Procedural Services). CPT 75774 is 
inclusive to Common Procedural Terminology (CPT) 37242 Vascular embolization or occlusion, inclusive of 
all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary 
to complete the intervention; arterial, other than hemorrhage or tumor (eg, congenital or acquired arterial 
malformations, arteriovenous malformation, arteriovenous fistulas, aneurysms, pseudoaneurysms). The 
documentation does not support distinct procedural services were performed on this date of service. 
 
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 radiology services (CPT 75774) provided to the enrollee on November 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral exam (D0150) provided July 13, 2020. 
 
You asked the Plan to pay for the comprehensive oral exam. You say that the service was medically necessary. 
The Plan denied your request. The Plan says the benefit for this service has 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, the benefit for comprehensive oral 
exams has been exhausted. This service is covered once every 3 years. This service was last provided on  
November 7, 2019. Therefore, we decided that the Plan does not have to pay for a comprehensive oral exam 
(D0150) provided July 13, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waivethe copayment for the echocardiography you received on May 14, 2020.You asked the Plan to waivethe copayment. The Plandenied your request. The Plan says you are responsible for the copayment.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 $235 copayment for each covered diagnostic procedure or test at a network outpatient facility. Review of the file show that you had an echocardiography on May 14, 2020. You have been asked to pay a $235 copayment for the services. The echocardiography falls within the outpatient 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 waivethe copayment for the echocardiography you received on May 14, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic procedures (97112 x 2) provided January 14, 
2020. 
 
You asked the Plan to pay for therapeutic procedures. You say that the services provided are medically 
necessary. The Plan denied your request. The Plan says the services are not supported in the medical records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 therapeutic procedures Our reviewer says 
that the billed services are not supported. Our physician reviewer found the procedure report documents 49 
minutes spent on therapeutic services, which would not support the billed units. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapeutic procedures have not been met. Therefore, we decided that the Plan 
does not have to pay for therapeutic procedures (97112 x 2) provided January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services that you provided on May 22, 2020. 
 
You asked the Plan to pay for the physician's services. You say that you are a participating provider with this 
Plan. The Plan denied your request. The Plan says 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 also says that you are not a network provider. 
 
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 
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 physician's services that you provided on May 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fora reline complete maxillary denture (D5750) provided July 8, 2020.You asked the Plan to pay forthe denture. You say that the provider was in-network and the services should be covered.The Plan denied your request. The Plan says this item 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 fora reline complete maxillary denture (D5750) provided July 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental code D2740 (crown on tooth 28) provided on 
February 12, 2020. 
 
You asked the Plan to pay for dental code D2740. You say that you thought this service would be covered. The 
Plan denied your request. The Plan says D2740-crown was denied on tooth 28 due to a clinically unacceptable 
root canal that was performed. 
 
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. The Plan covers dental code 
D2740 when the services are medically necessary and reasonable.  
 
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 dental code D2740. Our reviewer says that 
dental code D2740 did not meet the Plan's coverage criteria. Our physician reviewer found the request has been 
made for a crown for tooth #28.  The existing root canal fill on the tooth is inadequate, being several 
millimeters short of the radiographic apex (at least 4mm), and the remainder of the fill clearly inadequately 
condensed.  In order to proceed with treatment on a tooth for restorative procedures, the endodontic seal must 
be adequate to ensure the best chances for a good long term prognosis.  If a tooth does not have a favorable 
restorative prognosis, restorative treatment may not be indicated. The Policy states that "root canals are 
covered once per tooth per lifetime, and recementing of crowns are covered once per tooth every two calendar 
years. However, root canal therapy must be completed with filling material accepted by the Federal Food and 
Drug Administration, the fill must be properly condensed/obturated and must be within two millimeters of the 
radiological apex (unless there is a curvature or calcification of the canal that limits ability to fill canal to apex) 
without extending significantly beyond the apex of the tooth."  In this case the endodontic fill is clearly short 
by more than two millimeters and the remainder of the fill is poorly condensed.  Given the policy criteria, and 
standard endodontic practice parameters, there is no necessity for the procedure and policy criteria have not 
been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of dental code D2740 have not been met. Therefore, we decided that the Plan does 
not have to pay for dental code D2740 (crown on tooth 28) provided on February 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT scan) of the 
abdomen and pelvis you had on January 23, 2020. 
 
You asked the Plan to waive the copayment for the CT scan. You say that this service should be paid in full 
because this copayment isn't listed on your ID card. 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 $150 
copayment for complex radiology services, including CT scans.  
 
You have been asked to pay a $150 copayment for the CT scan.  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. The Plan is not obligated to list every single cost sharing amount 
on your ID card.  The Plan, instead, is required to disclose all cost sharing amounts to you in the Evidence of 
Coverage booklet and they have done so. Therefore, we decided that the Plan does not have to waive the 
copayment for the computed tomography (CT scan) of the abdomen and pelvis you had on January 23, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayment for the ultrasound exam of the abdomen 
(76700) and transvaginal ultrasound (76830) provided on January 23, 2020. 
 
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
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 each Medicare-covered radiological diagnostic service, not including x-rays, performed in a 
physician's office or at a freestanding facility (such as a radiology center or medical clinic).  
 
You have been asked to pay $220 ($110 copayment x 2 tests) for the Medicare-covered radiological diagnostic 
services provided. 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 adjust the copayment for the ultrasound exam of the 
abdomen (76700) and transvaginal ultrasound (76830) provided on January 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for needle electromyography (95861) provided April 1, 2020. 
 
You asked the Plan to pay for needle electromyography. You say that the service provided was medically 
necessary. The Plan denied your request. The Plan says the medical records do not support billing the code. 
 
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 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 needle electromyography. Our reviewer says 
that the medical records provided do not include sufficient documentation to verify this service was performed. 
Our physician reviewer found the documentation does not confirm that needle electrodes were used in 
performing this service. Support for this code is not documented in the operative note. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of needle electromyography have not been met. Therefore, we decided that the 
Plan does not have to pay for needle electromyography (95861) provided April 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe established patient office or other outpatient visit (99213) provided on February 24, 2020, by an out of network (OON) provider.You asked the Plan to pay fortheestablished patient office or other outpatient visit. 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 by the facility or the provider; therefore, payment has been correctly denied.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 forthe established patient office or other outpatient visit (99213) provided on February 24, 2020, by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the X-ray services (74230, 70100, 99204, 72040) provided 
on June 26, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the x-ray services. You say that the care you provided was medically necessary. 
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 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 X-ray services (74230, 70100, 99204, 72040) 
provided on June 26, 2020, by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient alcohol detox services provided from April 18, 
2020 to April 22, 2020. 
 
You asked the Plan to pay for the inpatient alcohol detox services provided from April 18, 2020 to April 22, 
2020. You say that the inpatient alcohol detox services provided from April 18, 2020 to April 22, 2020 were 
medically necessary. The Plan denied your request. The Plan says the inpatient alcohol detox services provided 
from April 18, 2020 to April 22, 2020 were 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 pay for the inpatient alcohol detox services provided 
from April 18, 2020 to April 22, 2020. Our reviewer says that the inpatient alcohol detox services provided 
from April 18, 2020 to April 22, 2020 were not medically necessary. Our physician reviewer found the enrollee 
was admitted to the acute inpatient psychiatric/detoxification hospital on April 18, 2020 with Alcohol Abuse 
with Intoxication Unspecified. Based upon review the records provided it was not expected this enrollee would 
improve in a reasonable period of time as he did not have dangerousness to self or others, auditory or visual 
hallucinations, delusions and was not showing any behavioral issues. He was not undergoing any withdrawal 
symptoms and his vital signs were found to be unremarkable with a temperature of 97.5, pulsating, respirations 
18 and a blood pressure 107/63. He was not exhibiting any acute withdrawal symptoms from alcohol. 
 
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 inpatient alcohol detox services provided from April 18, 2020 to April 22, 
2020 have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient alcohol 
detox services provided from April 18, 2020 to April 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayment for the office visits (99213) and the aflibercept 
injections (J0178) provided on April 6, 2020 and May 11, 2020. 
 
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
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 20% 
coinsurance for Medicare covered Part B drugs and other Medicare covered items, or a $15 copayment per day 
for drugs that are professionally administered, and an office visit copayment may apply. Additionally, you are 
responsible for a $15 copayment for each specialist visit for Medicare covered services.  
 
You have been asked to pay $60 ($15 copay x 2 visits + $15 copay x 2 injections) for the Medicare Part B 
drugs administered and the specialist visits provided. 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 adjust the copayment for 
the office visits (99213) and the aflibercept injections (J0178) provided on April 6, 2020 and May 11, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from March 30, 2020 to April 28, 2020. 
 
You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan 
denied your request. The Plan says Medicare coverage criteria were not met.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 
pay for this service. Our reviewer says that daily skilled services are not necessary. Our physician reviewer 
found the enrollee did not require daily skilled nursing or daily skilled therapy services. The enrollee did not 
meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee from March 30, 2020 to April 
28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee and billed 
under code 14061. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare billing criteria are not met. 
 
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 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 this service. Our reviewer says that Medicare billing criteria are not met. Our physician 
reviewer found the enrollee received services for Common Procedural Terminology (CPT) 
14061  described as ?Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10.1 sq 
cm to 30.0 sq cm.?  The documentation submitted was reviewed. The operative report does not support an 
adjacent tissue transfer or arrangement.  Medicare billing criteria are not met. We looked at this physician's 
review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 
this service have not been met. Therefore, we decided that the Plan does not have to pay for physician services 
provided to the enrollee and billed under code 14061.