Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4649 and E1399 billed for date of service 
January 14, 2022. 
 
You asked the Plan to pay for procedure codes A4649 and E1399. You say that these items should be covered. 
The Plan denied your request. The Plan says procedure code A4649 is considered bundled and not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. The rules also say that a concise 
description of an "unlisted procedure code" or a not otherwise classified (NOC) code should be entered in box 
19 of the claim or in an attachment. 
 
We find that procedure code A4649 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A4649 is not separately payable. E1399 is a miscellaneous code and a description of what it is 
being used to bill was not included with the claim. Based on this information, we decided that Medicare rules 
for coverage of procedure codes A4649 and E1399 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes A4649 and E1399 billed for date of service January 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified mass spectrometry testing provided on June 
15, 2022, billed with code 83789. 
 
You asked the Plan to pay for the unspecified mass spectrometry testing. You say that it is felt that the testing 
should be approved as medically necessary. The Plan denied your request. The Plan says the drug testing itself 
was paid, but the other testing represents validity testing that cannot be separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the unspecified mass spectrometry testing have not been met. Specifically, we find that the testing 
described by the billed code is considered specimen validity testing which is not separately payable. Therefore, 
we decided that the Plan does not have to pay for the unspecified mass spectrometry testing provided on June 
15, 2022, billed with code 83789.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft for ridge preservation - per site 
(D7953) provided on August 11, 2022. 
 
You asked the Plan to pay for the bone replacement graft for ridge preservation - per site (D7953). You say that 
you had a toothache and the Plan should cover this important service. The Plan denied your request. The Plan 
says this service is not covered under the benefit package. 
 
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 a bone 
replacement graft for ridge preservation - per site (D7953) provided on August 11, 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 July 8, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that you would like this claim reprocessed and 
approved for payment. 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 July 8, 2022, billed with 
code 99153.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction, erupted tooth or exposed root (D7140) 
provided on July 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you tried to have the extraction performed in-
network. You also say that you were informed your portion of the bill would be $440.00 and are asking to be 
reimbursed by 50% if possible. 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. 
 
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, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for an extraction, erupted tooth or exposed root (D7140) provided on July 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on August 19, 2022, to August 
29, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for chiropractic services. You say that you did not know the provider was not in-
network, if you did you would have chosen a different provider. The Plan denied your request. The Plan says 
the service can be provided by an in-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 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 chiropractic services provided on August 19, 
2022, to August 29, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid provided on June 15, 2022. 
 
You asked the Plan to pay for the hearing aid. You say that you found the provider through the Plan's website. 
The Plan denied your request. The Plan says the hearing aid was not purchased through the Plan's hearing 
network. 
 
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 provided by network providers. 
 
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 aid have not been met. Specifically, the provider was out-of-network. Therefore, we 
decided that the Plan does not have to pay for the hearing aid provided on June 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency one-way trips. 
 
You asked the Plan to pre-approve transportation services. You say that you need more transportation services. 
The Plan denied your request. The Plan says you have exhausted the covered benefit of your plan. 
  Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips every year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency one-way trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (00731) billed for date of service June 24, 
2022. 
 
You asked the Plan to pay for anesthesia services. You say that the services at issue have been billed correctly. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service, 
excepting enrollees who are registered hospital inpatients or outpatients, in which case, the inpatient or 
outpatient hospital POS code would be reported regardless of where the face-to-face service takes place. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of anesthesia services have not been met. Specifically, the submitted medical records document that 
the enrollee was admitted as an inpatient on the date of service in question. The services at issue have been 
inappropriately billed with an outpatient POS code. Therefore, we decided that the Plan does not have to pay 
for anesthesia services (00731) billed for date of service June 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory pathogen panel billed with multiple procedure 
codes including 87632 and 87634 for date of service January 26, 2022. 
 
You asked the Plan to pay for the respiratory pathogen panel. You say that this testing was necessary and is 
supported as billed. The Plan denied your request. The Plan says these services were not billed in accordance 
with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a respiratory pathogen panel test must not be 
unbundled and billed as individual components regardless of the fact that the panel reports multiple individual 
pathogens and/or targets.  We looked at the file and Medicare rules. The panel in question was unbundled and billed as multiple 
components. Based on this information, we decided that Medicare rules for coverage of the respiratory 
pathogen panel have not been met. Therefore, we decided that the Plan does not have to pay for the respiratory 
pathogen panel billed with multiple procedure codes including 87632 and 87634 for date of service January 26, 
2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit for the evaluation and 
management of a patient (CPT code 99285) provided on June 18, 2022. 
 
You asked the Plan to pay for the service. You say that the enrollee was seen twice on the same date of service 
at two different times and or by two different providers. The Plan denied your request. The Plan says the 
service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. Code 99285 (Emergency 
department visit for the evaluation and management of a patient) billed by the provider for date of service June 
18, 2022, was denied as a duplicate claim line because it has been previously processed. Per review of the 
claim, Code 99285 was billed for the same date of service and already processed and paid on July 3, 2022, to 
another provider. Both the providers specialties were listed as Emergency Medicine under the same Tax ID, 
and both the claims were billed under same billing group. 
 
Review of the documentation shows the enrollee was seen by the paid provider and the enrollee left against 
medical advice (AMA) with promise to return. Again, the enrollee returns to the emergency department and 
seen by the billing provider at 5:00 PM for same the condition (Abdomen pain), got admitted for further 
evaluation and management. However, does not indicate that both visits were performed for unrelated 
problems as per the Medicare guidelines. A modifier was not billed on the claim to represent both evaluation 
and management service as separate and significant. Therefore, we decided that the Plan does not have to pay 
for the emergency department visit for the evaluation and management of a patient (CPT code 99285) provided 
on June 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - complete series of radiographic images 
(D0210), and caries risk assessment and documentation (D0603) provided on August 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not told that you needed to get your x-
ray from a specific dental provider or you would be charged. You also say you were told insurance covers all 
expenses. 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the intraoral - complete series of radiographic images (D0210) service was exhausted on 
date of service June 8, 2021.  Therefore, we decided that the Plan does not have to pay for an intraoral - complete series of radiographic 
images (D0210), and caries risk assessment and documentation (D0603) provided on August 22, 2022.  The 
Plans dental benefits do not include coverage for the caries risk assessment and documentation (D0603).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
June 29, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service June 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 4, 2022, billed with 
codes 81162, 81292, 81295, 81298, 81317, 81321, 81351, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 4, 2022, billed with codes 81162, 81292, 81295, 81298, 81317, 81321, 81351, and 81479.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 6, 2022, billed with 
codes 0031U, 0032U, 81225, 81227, 81230, 81231, 81291, and 81355. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 6, 2022, billed with codes 0031U, 0032U, 81225, 81227, 81230, 81231, 81291, and 81355.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 9, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 9, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee should only require short-term additional acute care services that can 
safely be administered at the current facility until more appropriate for a lower level of care. The enrollee does 
not require services at the LTACH that are not already available at the current facility. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on March 24, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the testing services. You say that the test results influence treatment and care 
decisions. The Plan denied your request. The Plan says the services were incorrectly coded and 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 file shows that definitive drug testing of 15-21 drug classes (CPT code G0482) was billed. We find that 
CPT code G0482 is not supported in the medical records. The records do not show that 15-21 drug classes were 
provided. The provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. 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 the drug testing services provided on March 24, 2022, by an out-
of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to reduce the coinsurance for outpatient therapies. We decided that the Plan 
does not have to waive the coinsurance for outpatient therapies.  
 
You asked the Plan to waive the coinsurance for outpatient therapies provided on June 24, 2022. You say that 
you met your out-of-pocket maximum. The Plan says that this cost sharing was charged correctly. 
 
 
 We decided that the Plan has to reduce the coinsurance for outpatient therapies.  
 
You cannot be asked to pay more than a 20% coinsurance for outpatient rehabilitation services. Therefore, we 
decided that the Plan has to waive the coinsurance for outpatient therapies.  
 
We also decided that the Plan does not have to waive the coinsurance for outpatient therapies. 
 
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 of the allowed amount for outpatient therapies. The total allowed amount is $61.76. The total 
amount you are being asked to pay is $12.35 ($61.76 x 20% = $12.35). Therefore, we decided that the Plan 
does not have to waive the coinsurance for outpatient therapies. 
 
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.