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

 
We decided that the Plan does not have to pay for the 3D rendering with interpretation and reporting of 
computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image 
post processing under concurrent supervision services coded 76377 provided. 
 
You asked the Plan to pay for the 3D rendering with interpretation and reporting of computed tomography, 
magnetic resonance imaging, ultrasound, or other tomographic modality with image post processing under 
concurrent supervision 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 payable. 
 
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 76377 is 3D rendering with interpretation and reporting 
of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image 
post processing under concurrent supervision; requiring image post processing on an independent workstation.  
 
Review of the file shows that the plan uses Local Coverage Determination LCD L35408 to support their denial. 
However, this LCD is not valid for the provider?s state of New York. Therefore, we cannot use LCD L35408 to 
substantiate our decision. 
 
We find that CPT code 76377 is not supported in the medical record. Specifically, this service is included in the 
 
 
authorized radiologic procedure. This code is not separately payable. Based on this information, we decided 
that Medicare rules for coverage of the 3D rendering with interpretation and reporting of computed 
tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image 
post processing under concurrent supervision services have not been met. Therefore, we decided that the Plan 
does not have to pay for the 3D rendering with interpretation and reporting of computed tomography, magnetic 
resonance imaging, ultrasound, or other tomographic modality with image post processing under concurrent 
supervision services coded 76377 provided.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound rendered on June 9, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The 
Plan denied your request. The Plan says the copayment was applied 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 $125 
copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in an 
physician's office or at a free-standing facility.  
 
Review of the file shows that you received an ultrasound on June 9, 2020. You have been asked to pay a $125 
copayment for these services. These services fall within the Medicare-covered radiological diagnostic service, 
not including x-rays, performed in an physician's office or at a free-standing facility 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 the ultrasound rendered on June 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intermittent limb compression device (E0651, E0667) 
provided on July 1, 2020. 
 
You asked the Plan to pay for an intermittent limb compression device. You say that this is supported by the 
records. The Plan denied your request. The Plan says the records do not support that the enrollee had a covered 
condition. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. The submitted medical records indicate the enrollee was negative for edema and ulcers. 
Therefore, we decided that the Plan does not have to pay for the intermittent limb compression device (E0651, 
E0667) provided on July 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extremity brace provided to the enrollee on May 7, 2020. 
 
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 lack in-person assessment information such as motion or strength tests and the 
member denies speaking with this physician. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for an extremity brace provided 
to the enrollee on May 7, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colonoscopy rendered on August 13, 2020. 
 
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 provider has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
colonoscopy rendered on August 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a TENS unit (E0745) provided to the enrollee on June 26, 
2020. 
 
You asked the Plan to pay for the TENS unit. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
 
 
 
 
 
 
 
 
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a TENS unit (E0745) 
provided to the enrollee on June 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite provided on February 27, 2020. 
 
You asked the Plan to pay for the resin-based composite. You say that the Plan has not covered any of your 
dental services. The Plan denied your request. The Plan says this service is not a covered benefit under your 
plan. The Plan also says that you have coverage for routine dental services including dental exams, cleanings, 
and bitewing x-rays or full mouth diagnostic x-rays. 
 
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 resin-
based composite provided on February 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care (99223) provided on July 10, 2020. 
 
You asked the Plan to pay for the initial hospital care. You say that you would like reconsideration because 
these services were rendered by different providers. The Plan denied your request. The Plan says CPT code 
99233 was billed twice on the same date of service by the same provider. 
 
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 code 99223 is not supported in the record. Specifically, the record indicates that CPT code 
99232 billed twice by the same provider on the same date of service. CPT code 99233 may only be billed once 
per day by the same physician. Based on this information, we decided that Medicare rules for coverage of the 
initial hospital care have not been met. Therefore, we decided that the Plan does not have to pay for initial 
hospital care (99223) provided on July 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services (72100, 99203, and 98941) provided to 
the enrollee. 
 
You asked the Plan to pay for services not related to manual manipulation of the spine. You say that these 
services should be covered by the Plan. The Plan denied your request. The Plan says the services billed are not 
covered when rendered by a chiropractor. 
 
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 chiropractic 
services (72100, 99203, and 98941) provided to the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric service provided on May 26, 2020 by an out 
of network provider. 
 
You asked the Plan to pay for the psychiatrist service. You say that the Plan referred you to the out of network 
provider. The Plan denied your request. The Plan says you did not have a valid authorization for this date of 
service. 
 
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 with a referral. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
The original referral expired on April 13, 2018. We found no exception that would require the Plan to pay for 
the service. Therefore, we decided that the Plan does not have to pay for the psychiatric service provided on 
May 26, 2020 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for graft for ridge preservation (D7953) provided on July 14, 
2020. 
 
You asked the Plan to pay for the bone graft. You say that you had a loose crown on tooth # 2. You say that the 
crown could not be reinstalled. You say that tooth # 29 was extracted as a result. You also say that the 
procedure you had done was the most practical, safe, long lasting and cost effective procedure. The Plan denied 
your request. The Plan says the bone replacement graft is 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 graft for 
ridge preservation (D7953) provided on July 14, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $40 total co payment charged for physician services 
provided.  
 
You asked the Plan to waive this service. You say that you do not believe these co payments are correct. The 
Plan denied your request. The Plan says each co payment is a contractual co payment per the Plan contract 
agreement. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $10 for 
each individual therapy services. 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 $40 total co payment charged for physician 
services provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hearing aid (V5255) provided on February 4, 2020. 
 
You asked the Plan to pay for a hearing aid. You say that the service should be covered. The Plan denied your 
request. The Plan says this service is not covered under your Plan benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related 
services.  
 
Though a hearing aid may be appropriate in this case, neither Medicare nor the Plan covers or pays for these 
types of items and services. Therefore, we decided that the Plan does not have to pay for a hearing aid (V5255) 
provided on February 4, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 30, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the duplex scan. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says a prior authorization is required for all services 
rendered by out-of-network providers, which was not obtained. 
 
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 June 30, 2020 by an out of network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture provided from May 18, 2020, to June 24, 2020 
out of network. 
 
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 out of network providers are not covered for routine services. The Plan also 
says that acupuncture is not a covered benefit under this contract. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, covered benefits and coinsurance). Your contract with the Plan clearly says that you 
must use in network providers. Your Plan contract clearly states that acupuncture is not a covered benefit.   
Therefore, we decided that the Plan does not have to pay for acupuncture provided from May 18, 2020, to June 
24, 2020 out of network.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient office visit (99214) and 
evaluation of wheezing (94060) and a mouth piece (A4617) provided May 7, 2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that this was a telehealth visit with this 
provider and you have a letter showing copays should be waived at this time. The Plan denied your request. 
The Plan says the claim processed and the correct copayment was applied per the plan benefits. 
 
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 DME and supplies and $30 copayment per visit to a specialist.  
 
You have been asked to pay $30.16 ($30 specialist visit + $0.16 DME item) for the office visit. The office visit 
falls within the Durable medical equipment (DM) and related supplies and Physician/Practitioner services, 
including doctor's office visits 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 outpatient 
office visit (99214) and evaluation of wheezing (94060) and a mouth piece (A4617) provided May 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 Power Wheelchair and accessories. 
 
You asked the Plan to pre-approve the Group 2 Power Wheelchair and accessories. You say that you would 
like reconsideration because the wheelchair is medically necessary. The Plan denied your request. The Plan 
says there is a lack of documentation to support that the member would be unable to do functional weight shifts 
with the use of a single power option with power tilt available on a less specialized wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 Group 2 Power Wheelchair and 
accessories. Our reviewer says that the documentation does not indicate that the member is at high risk for 
development of a pressure ulcer, utilizes intermittent catheterization for bladder management or requires a 
power seating system to manage increased tone or spasticity. The member does not use a ventilator. Our 
physician reviewer found the documentation does not support the need for the member to have the combination 
tilt and recline power seating system. 
 
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 Group 2 Power Wheelchair and accessories have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Group 2 Power Wheelchair and accessories.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for radiology services (CPT 71045) provided to the enrollee on July 1, 
2020. 
 
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 that the x-ray is not supported as being performed as a separate service from the included post 
procedure x-ray that is included in the thoracentesis. 
 
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 71045 is "Radiologic examination, chest; single view." 
 
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 services. Our reviewer says that the 
services at issue in this case were supported by the medical records. Our physician reviewer found while the 
procedure note of the chest tube placement is not in the records the dictation of the chest x-ray in question was 
7/1/20 and the report describes an unchanged location of the bilateral chest tubes since the prior day indicating 
that this new chest x-ray which was compared to a prior exam of 4:56 AM showed no change in the chest tube 
locations. The only way such a comparison could have been made was to compare the post procedure chest x-
ray to a new chest x-ray at 07:30 AM on 7/1/20, thus indicating the chest x-ray of dispute was a separate x-ray 
unrelated to the procedure itself. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
radiology services (CPT 71045) provided to the enrollee on July 1, 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.