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

 
We decided that the Plan does not have to pay for procedure code 88342 billed for date of service February 23, 
2022. 
 You asked the Plan to pay for procedure code 88342. You say that you added modifier 59 to this code, so it 
should be paid. The Plan denied your request. The Plan says payment for code 88342 is bundled into payment 
for code 88360. 
 
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 88342 
is a column II code to column I code 88360. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Please note that the 
claim had two lines of 88342 billed.  One line was billed with modifier 59.  That claim line was paid. The other 
line of code 88342 was not billed with a payment modifier, and that is the one that has been denied. Therefore, 
we decided that the Plan does not have to pay for procedure code 88342 billed for date of service February 23, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99253 billed for date of service July 10, 
2022. 
 
You asked the Plan to pay for procedure code 99253. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
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 99253 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99253 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code 99253 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99253 billed for date of service July 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs (A9270) provided from  
February 21, 2022, through February 23, 2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs provided are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
(A9270) provided from February 21, 2022, through February 23, 2022.  
 Benefits for these items may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not require the intensity of services provided at an 
IRF. Specifically, the enrollee is not shown to require, or to be able to tolerate, fifteen hours per week of rehabilitative services and regular physician evaluation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation - new/established patient 
(D0150), panoramic radiographic image (film) (D0330) and mandibular partial denture-cast metal framework 
with resin denture bases (D5214) provided on September 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you lost your bottom denture and don't have the 
money to pay this bill. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already 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. This benefit includes the 
requested comprehensive oral evaluation - new/established patient (D0150) but is limited to one procedure 
code every 3 calendar years, panoramic radiographic image (film) (D0330) but is limited to one procedure code 
every 5 calendar years, and mandibular partial denture-cast metal framework with resin denture bases (D5214) 
but is limited to one upper and/or one lower partial denture every 5 calendar years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested comprehensive oral evaluation - new/established patient (D0150) and 
panoramic radiographic image (film) (D0330) was exhausted on date of service June 18, 2020, and mandibular 
partial denture-cast metal framework with resin denture bases (D5214) was exhausted on date of service July 
21, 2020. Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation - 
new/established patient (D0150), panoramic radiographic image (film) (D0330) and mandibular partial 
denture-cast metal framework with resin denture bases (D5214) provided on September 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) purchased on  
May 17, 2022. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these items are not payable as they were 
purchased from an out-of-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 purchased from the Plans select hearing aid provider.  
 
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids must be 
purchased from the Plans select hearing aid provider. Hearing aids purchased outside of the Plans network are 
not covered. The hearing aids in this case were purchased from an out-of-network provider. Therefore, we 
decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) purchased on May 17, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical eye exam and the refraction provided on July 11, 
2022. 
 
You asked the Plan to pay for the medical eye exam and the refraction. You say that you have seen this doctor 
for years and the services have always been covered. You say you were not notified that your provider was 
taken out of the network. The Plan denied your request. The Plan says the provider was out-of-network.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when services are provided by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the medical eye exam and the refraction have not 
been met. Therefore, we decided that the Plan does not have to pay for the medical eye exam and the refraction 
provided on July 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 16, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an oral evaluation (D0120), intraoral radiographic 
images (D0230), bitewings (D0274), and a prophylaxis (D1110) provided on September 16, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you would like the Plan to pay the correct 
amount for the dental services. The Plan denied your request. The Plan says you are responsible for any 
charged amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. 
 
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. 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. The record shows your benefit for the intraoral radiographic images was exhausted on the date of 
service September 16, 2022. 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 pay more for an oral evaluation (D0120), 
intraoral radiographic images (D0230), bitewings (D0274), and a prophylaxis (D1110) provided on September 
16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hearing aid (V5298) provided on May 23, 2022. 
 
You asked the Plan to pay for a hearing aid (V5298). You say that it was not possible for you to do this through 
an in-network facility. The Plan denied your request. The Plan says There is no coverage if hearing aids, or 
related services are received from outside of the Plan Hearing network. The Plan also says that the hearing 
benefit is not covered if the services are not registered in advance. 
 
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 the hearing aids are purchased from an in-network provider.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of a hearing aid (V5298) have not been met. Therefore, we decided that the Plan does not have to pay 
for a hearing aid (V5298) provided on May 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crowns (D2740 x 2) on tooth numbers 13 and 14 
provided on April 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. The Plan denied 
your request. The Plan says this service is not a covered benefit under your dental plan. 
 
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 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 
crowns (D2740 x 2) on tooth numbers 13 and 14 provided on April 12, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport 
(A0429) and ground mileage (A0425) provided on July 14, 2022. 
 
You asked the Plan to pay for ambulance service, basic life support, emergency transport (A0429) and ground 
mileage (A0425). You say that you have attached medical records in support of this claim. The Plan denied 
your request. The Plan says on this date of service the patients claims history indicates they were in an 
inpatient hospital status. 
 
  The Plan must follow Medicare rules. Medicare rules say that the rules state that once a beneficiary is admitted 
to a hospital, critical access hospital, or skilled nursing facility, it may be necessary to transport the beneficiary 
to another hospital or other site temporarily for specialized care while the beneficiary maintains inpatient status 
with the original provider. This movement of the patient is considered patient transportation and payment is 
made under Part A for the service. Because the service is covered and payable as a beneficiary transportation 
under Part A, the service cannot be classified and paid for as an ambulance service under Part B.  
 
We looked at the file and Medicare rules. The record shows that the enrollee was transported while an 
inpatient, so this is paid under Medicare Part A and is not separately payable. Based on this information, we 
decided that Medicare rules for coverage of ambulance service, basic life support, emergency transport 
(A0429) and ground mileage (A0425) have not been met. Therefore, we decided that the Plan does not have to 
pay for ambulance service, basic life support, emergency transport (A0429) and ground mileage (A0425) 
provided on July 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an oral evaluation (D0120), intraoral 
radiographic image (D0220), fluoride varnish (D1206), and the periodontal maintenance (D4910) provided on 
February 1, 2022, and May 3, 2022. 
 You asked the Plan to waive the coinsurance for the dental services. You say that the rendering provider is an 
in-network provider. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 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 preventive and comprehensive dental services from an out-of-network provider. For February 
1, 2022, the total allowed amount for the oral evaluation was $62 with a coinsurance of $12.40 ($62 total x 
20% coinsurance). The total allowed amount for the periodontal maintenance was $168 with a coinsurance of 
$33.60 ($168 total x 20% coinsurance). For May 3, 2022, the total allowed amount for the intraoral 
radiographic image was $40 with a coinsurance of $8 ($40 total x 20% coinsurance). The total allowed amount 
for the fluoride varnish was $25 with a coinsurance of $5 ($25 total x 20% coinsurance). The total allowed 
amount for the periodontal maintenance was $168 with a coinsurance of $33.60 ($168 total x 20% 
coinsurance). The total coinsurance amount for both dates of service was $92.60 ($12.40 coinsurance + $33.60 
coinsurance + $8 coinsurance + $5 coinsurance + $33.60 coinsurance). 
 
You have been asked to pay a $92.60 coinsurance for the dental services. This item/service falls within the 
Dental 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 coinsurance for an oral evaluation 
(D0120), intraoral radiographic image (D0220), fluoride varnish (D1206), and the periodontal maintenance 
(D4910) provided on February 1, 2022, and May 3, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the JAK2 gene testing (81270) provided on November 8, 2021. 
 
You asked the Plan to pay for the JAK2 gene testing. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that repeat testing of JAK2 mutation on bone 
marrow sample was not recommended. 
 
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. The Plan says repeat genetic testing on bone marrow was not medically 
necessary because the enrollee already had peripheral blood with JAK2 mutation. The file shows that the Plan's 
decision was based on review of medical record documentation the Plan says showed that the enrollee already 
received this genetic testing; however, the Plan provided none of these records for review to confirm if the 
Plan's denial reason is valid based on Medicare criteria. The Plan has not shown that the enrollee already 
received this genetic testing. Therefore, we decided that the Plan has to pay for the JAK2 gene testing (81270) 
provided on November 8, 2021.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for interim partial denture replacing (D5821) teeth #18, #19, 
#20, and #21 and maxillary complete denture (D5110) provided on June 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed the provided services so you could 
chew food. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted and the service is covered but limitations apply. 
 
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. This benefit includes the 
requested maxillary complete denture (D5110) but is limited to once every five years. Interim partial denture 
replacing (D5821) but is limited to only when replacing permanent anterior teeth during the healing period or 
for people aged 16 and under for missing permanent anterior teeth. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested maxillary complete denture (D5110) was exhausted on date of service 
September 2, 2021. The requested interim partial denture replacing (D5821) is limited to only when replacing 
permanent anterior teeth during the healing period or for people aged 16 and under for missing permanent 
anterior teeth. Therefore, we decided that the Plan does not have to pay for interim partial denture replacing 
(D5821) teeth #18, #19, #20, and #21 and maxillary complete denture (D5110) provided on June 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261, V5298) and the 
hearing services (V5299) purchased on July 19, 2022. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these items/services are not payable as they 
were purchased from an out-of-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/services only when purchased from the Plans select hearing aid provider.  
 
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items/services have not been met. Specifically, the Plans contract states that hearing 
aids/services must be purchased through the Plans select hearing aid provider. There is no coverage if hearing 
aids or related services are received from an out-of-network provider. The hearing aids/services in this case 
were purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5261, V5298) and the hearing services (V5299) purchased on July 19, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 08, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s).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, we 
decided that the Plan does not have to pay for an office visit provided on April 08, 2022.