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

 
We decided that the Plan does not have to pay for the hearing aids (V5261) purchased on June 3, 2022, from an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you received a more thorough hearing test through 
this OON provider, and the cost for the hearing aids was cheaper. You also say that you expected to be 
reimbursed the $1,399.00 that you spent. The Plan denied your request. The Plan says these hearing aids were 
purchased from a non-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are purchased through a Plan-approved hearing aid vendor.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids (V5261) purchased on June 3, 2022, from an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95910 billed for date of service April 13, 
2022. 
 
You asked the Plan to pay for procedure code 95910. You say that this service was necessary and was reported 
correctly. The Plan denied your request. The Plan says the payment for code 95910 is included in the payment 
for code 95861. 
 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, we have confirmed that code 95910 
is a column II code to column I code 95861 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 95910 billed for date of service April 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 19, 2022, by an OON 
provider. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says the out-of-network 
services were not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit provided on July 19, 2022, by an 
OON provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mental health visits provided on November 3, 2021, to 
November 30, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for mental health visits. You say that this should be covered as it was medically 
necessary for this beneficiary. The Plan denied your request. The Plan says there was no preauthorization by a 
primary care provider (this is different than a referral) for an out-of-network (OON) provider or facility, and 
this was not an emergency. Therefore, the decision is upheld. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for mental health visits provided on November 3, 
2021, to November 30, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breast ultrasound provided on July 07, 
2022. 
 
You asked the Plan to waive the copayment for a breast ultrasound. You say that you are experiencing a 
financial hardship and need this copayment waived. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $100 copayment for a breast ultrasound. This item/service 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. You have been asked to pay the allowed amount of 
$98.58 which is less than the $100 copayment for an ultrasound. Therefore, we decided that the Plan does not 
have to waive the copayment for a breast ultrasound provided on July 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99153) provided on June 13, 
2022. 
 
You asked the Plan to pay for moderate sedation services (99153). You say that medical records are attached, 
and the claim should be reprocessed. The Plan denied your request. The Plan says procedure code 99153 may 
not be paid if furnished to hospital inpatients or patients in a hospital outpatient department.  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 99153 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service). 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, procedure code 99153 is a 
TC only code and the claim indicates that this service was rendered in a facility setting. Payment for procedure 
code 99153 is made to the facility and is the responsibility of the facility to any physician or vendor. Based on 
this information, we decided that Medicare rules for coverage of moderate sedation services (99153) have not 
been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99153) 
provided on June 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 83520, 84480, and 84436 billed for date of 
service February 2, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says payment for 
code 83520 is bundled into payment for code G0482. 
 
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 looked at the file and the rules. In this case, we have confirmed that code 83520 is a column II code to 
column I code G0482. This claim has not been billed with an appropriate modifier to bypass the edit. We have 
confirmed that code 84480 is a column II code to column I code 84481 with a modifier indicator of 0. The 
column II code is therefore not payable. We have also confirmed that code 84436 is a column II code to 
column I code 84439 with a modifier indicator of 0. These column II codes are therefore not payable. Based on 
this information, we have decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 83520, 84480, and 84436 billed for date of 
service February 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service October 13, 2021, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that this should be paid for. The Plan denied 
your request. The Plan says code 99153 is not payable in the facility setting. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does not have to pay for the additional moderate sedation time provided on date of service October 13, 2021, billed 
with code 99153.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 10 PT visits. You say that the enrollee needs PT. The Plan denied your 
request. The Plan says additional PT is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 10 PT visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the additional requested therapy generally is not accepted as 
specific and effective therapy for the enrollees condition beyond what was approved by the Plan. The enrollee 
has had prior therapy and the documentation does not reveal that the enrollee's functional level requires the 
unique skills of a professional therapist to safely and effectively provide treatment, that the services can be 
safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee 
is ambulating 300 feet his functional level does not require the additional 10 sessions beyond what was already 
approved by the Plan. He can transition to an independent home exercise program. The requested services are 
not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is 
not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to 
prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 10 additional physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), prophylaxis 
(D1110), and a panoramic x-ray (D0330) provided on May 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says the dental services were received from an out-of-network provider 
and are not covered by your supplemental benefits. The Plan also says that a panoramic x-ray (D0330) is not 
covered by your dental benefits. 
 
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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, a comprehensive oral evaluation and prophylaxis are not 
covered under this benefit when received from an out-of-network provider. A panoramic x-ray is not covered 
under this benefit. Therefore, we decided that the Plan does not have to pay for a comprehensive oral 
evaluation (D0150), prophylaxis (D1110), and a panoramic x-ray (D0330) provided on May 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9999 billed for date of service May 27, 
2022. 
 
You asked the Plan to pay for procedure code S9999. You say that please process again and pay the claim. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. Medicare does not 
reimburse separately for sales tax.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9999 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9999 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9999 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9999 billed for date of service May 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve echocardiography services represented by code 93355, 
intracardiac electrophysiologic 3-dimensional mapping represented by code 93613, comprehensive 
electrophysiologic evaluation represented by code 93656, and additional linear or focal intracardiac catheter 
ablation represented by code 93657. 
 
You asked the Plan to pre-approve codes 93355, 93613, 93656, and 93657. You say that the clinical 
documentation provided supports the need for the services which remain in dispute. The Plan denied your 
request. The Plan says the records do not mention an indication or plan to repeat ablation services, or that prior 
ablation was unsuccessful. The Plan says that the services which remain in dispute are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve codes 93355, 93613, 93656, and 93657. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee underwent atrial fibrillation ablation in October of 2022 with 
subsequent return of the arrhythmia. The guidelines do not support the performance of a repeat ablation 
procedure for atrial fibrillation until 3 months have passed since a previous catheter ablation procedure for 
atrial fibrillation; after 3 months, return of atrial fibrillation would confirm failure of the procedure, and a 
repeat procedure can be considered if clinically appropriate. At this time, repeat catheter ablation for atrial 
fibrillation would not be considered medically necessary in the management of this patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 93355, 93613, 93656, and 93657 have not been met. Therefore, we 
decided that the Plan does not have to pre-approve echocardiography services represented by code 93355, 
intracardiac electrophysiologic 3-dimensional mapping represented by code 93613, comprehensive 
electrophysiologic evaluation represented by code 93656, and additional linear or focal intracardiac catheter 
ablation represented by code 93657.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), intraoral - periapical 
first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), bitewing - 
single radiographic image (D0270) and panoramic radiographic image (D0330) provided on July 21, 2022. 
 
You asked the Plan to pay for the limited oral exam and x-rays. You say that you were told there would be no 
cost for the services. The Plan denied your request. The Plan says you have exhuasted your dental allowance. 
 
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. The Plan covers the limited 
oral exam and x-rays up to a $1,400 dental allowance every year. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that you have exhausted your dental allowance.  Therefore, we decided that the Plan does not have to pay for the limited oral evaluation 
(D0140), intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional 
radiographic image (D0230), bitewing - single radiographic image (D0270) and panoramic radiographic image 
(D0330) provided on July 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on December 13, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollees network primary care provider (PCP) or plan must give the enrollee 
approval in advance before they can use providers not in the plan's network. This is called giving the enrollee a 
"referral." 
 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for office visit provided on December 13, 2021, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
June 22, 2022. 
 
You asked the Plan to pay for F1CDx testing. You say that this test was medically reasonable and necessary. 
The Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of F1CDx testing have 
not been met. Therefore, we decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) 
(0037U) testing provided on June 22, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility visit provided on July 18, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for a skilled nursing facility visit. You say that this was a medically necessary visit 
and should be covered. The Plan denied your request. The Plan says there was no preauthorization by a primary 
care provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was 
not an emergency. Therefore, the decision is upheld. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a skilled nursing facility visit provided on July 18, 
2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided from July 6, 
2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you don't agree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for ambulance services.  
 
You have been asked to pay a $200 copayment for ambulance services. This item/service falls within the 
ambulance services 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 ambulance services 
provided from July 6, 2022.