Persius/hicric huggingface dataset:
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 August 15, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 
 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 August 
15, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for injection services (procedure code 36465) rendered on May 18, 2021. 
 
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 Current Procedural Terminology (CPT) code 36465 remains not supported. 
 
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 36465 is "Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide 
dispersion of the injectate, inclusive of all imaging guidance and monitoring; single incompetent extremity 
truncal vein (eg, great saphenous vein, accessory saphenous vein)." 
 
We asked our coder 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 reviewer found that there is satisfactory documentation 
that the services signified by CPT 36465 were rendered in this case. There is documentation that the procedure 
was performed under ultrasound guidance and that the Varithena was injected into the posterior accessory 
saphenous vein. There is documentation that there was significant reflux in that vein prior to treatment. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
injection services (procedure code 36465) rendered on May 18, 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 crown - porcelain/ceramic (D2740), prophylaxis - adult 
(D1110), periodic oral evaluation - established patient (D0120), and topical application of fluoride varnish 
(D1206) provided on May 2, 2022 to October 31, 2022. We also decided that the Plan does not have to waive 
the coinsurance applied to the gingivectomy or gingivoplasty (D4212) provided on May 2, 2022. 
 
You asked the Plan to pay for the dental services represented by dental codes D2740, D1110, D0120, and 
D1206. You also asked the  Plan to waive the coinsurance for code D4212. You say that you were not aware 
that the dentist was out-of-network. You also say that the secretary at the office informed you the provider 
accepted your insurance. The Plan denied your request. The Plan says your benefit for the dental codes 
represented by codes D2740, D1110, D0120, and D1206 $2,000 dollar limit was met. The Plan says the 
coinsurance was appropriately applied to the gingivectomy or gingivoplasty D4212. 
 
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. 
 
DATE OF 
SERVICE 
BEGINNING 
BALANCE 
TRANSACTION 
AMOUNT 
ENDING 
BALANCE 
3/22/2022 $0 $225.00 $225.00 
4/12/2022 $225.00 $125.00 $350.00 
4/26/2022 $350.00 $840.00 $1,190.00 
5/2/2022 $1,190.00 $810.00 $2,000.00 
 
You have been asked to pay a 35% coinsurance for the gingivectomy or gingivoplasty D4212 (the allowed 
amount $195 x 35% = $68.25).This service falls within the physician/practitioner services, including doctors 
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 coinsurance for the gingivectomy or 
gingivoplasty D4212 provided on May 2, 2022. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the dental codes represented by codes D2740, D1110, D0120, and D1206 was exhausted 
on date of service May 2, 2022. Therefore, we decided that the Plan does not have to pay for crown - 
porcelain/ceramic (D2740), prophylaxis - adult (D1110), periodic oral evaluation - established patient (D0120), 
and topical application of fluoride varnish (D1206) provided on May 2, 2022 to October 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames and single vision lenses provided on December 6, 
2022. 
 
You asked the Plan to pay for the frames and single vision lenses. You say that you will not pay the $12. The 
Plan denied your request. The Plan says the claim processed correctly.  
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 with a $200 allowance. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid $200 of the retail price for the frames and 
lenses. Based on this information, we decided that the Plan's rules for coverage of the frames and single vision 
lenses have not been met. Therefore, we decided that the Plan does not have to pay for the frames and single 
vision lenses provided on December 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair custom ramp. 
 
You asked the Plan to pre-approve a wheelchair custom ramp. You say that you are wheelchair bound and need 
assistance opening and placing a foldable ramp. You need an accessible ramp for safety. The Plan denied your 
request. The Plan says Medicare will pay for durable medical equipment that is mainly used to serve a medical 
purpose. Medicare will not pay for equipment used for comfort or for the convenience of a person caring for 
you. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair custom ramp.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient alcoholic rehabilitation. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says outpatient rehabilitation with an appropriate provider can be approved. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found based on a review of the records provided and utilizing the American Society of Addiction Medicine Adult Patient Placement 
Criteria for the Treatment of Psychoactive Substance Use Disorders, this patient was not at severe risk of 
withdrawal potential as was noted by the documentation that this patient was not showing any severity of 
withdrawal symptoms. The patients documentation does not present a biomedical condition/complication 
which requires this level of care. The documentation does not show an emotional or behavioral 
condition/complication which requires this level of care. This patient does have treatment acceptance willing to 
go into treatment for their condition. The documentation does not present an issue of relapse potential. There is 
no documentation regarding the recovery documentation. The patient does not meet the criteria for treatment in 
an acute inpatient rehabilitation treatment and could have been treated in a lesser restrictive setting as he was 
not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not 
showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to 
safety. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve inpatient alcoholic rehabilitation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. The Plan denied your request. The Plan says based on the 
information submitted, there is no documentation that you meet the criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have one of 
the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to 
pre-approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on September 23, 2021, to 
November 3, 2021. 
 
You asked the Plan to pay for the dental services. You say that you thought you were covered for the billed 
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. 
 
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 dental services provided on September 23, 2021, to November 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital claim for date of service May 5, 2022, 
to May 6, 2022. 
 
You asked the Plan to pay for the outpatient hospital claim. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that 
CMS designates to be inpatient-only services. These services have an OPPS status indicator of C in the 
OPPS Addendum B and are listed together in Addendum E of each years OPPS/ASC final rule. 
 The service at issue in this appeal was billed with code 27487. This code is listed with a status indicator of "C" 
on Addendum B of the 2022 OPPS/ASC final rule. This means the service has been designated as "inpatient 
only", and therefore must be billed as part of an inpatient admission. 
 
The rules also say that Medicare does not pay for all other services on the same day as the inpatient only 
procedure. Code 64447 was performed on the same day as code 27487, which is an inpatient only code. 
Therefore, we decided that the Plan does not have to pay for the outpatient hospital claim for date of service 
May 5, 2022, to May 6, 2022.
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 
November 14, 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 November 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Spravato. 
 
You asked the Plan to pre-approve Spravato. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is 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 requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Spravato.  
 
Benefits for Spravato 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of a CardioMEMS device (33289, 
C2624). 
 
You asked the Plan to pre-approve placement of a CardioMEMS device. You say that the requested services 
are a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 placement of a CardioMEMS device. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that at this time there remains a dearth of randomized, blinded clinical 
studies examining long-term clinical outcomes establishing the value of CardioMEMS in patient management. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of placement of a CardioMEMS device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve surgical placement of a CardioMEMS device (33289, C2624).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone graft (D7953). 
 
You asked the Plan to pre-approve a bone graft. You say that these services are medically necessary. The Plan 
denied your request. The Plan says these services have been correctly denied. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a bone graft have been met. The Plan 
made an attempt on March 7, 2023, and on March 9, 2023 to obtain dental x-rays. Therefore, we decided that 
the Plan does not have to pre-approve a bone graft (D7953).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 29, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 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 70450 
is a column II code to column I code 70496. 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. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service August 31, 
2022. 
 
You asked the Plan to pay for procedure code 86077. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service August 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatments (98941) rendered by 
an out-of-network (OON) provider from August 13, 2022, through October 25, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out-of-
network provider, without prior authorization. 
 
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. 
  
You are 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 chiropractic manipulative treatments (98941) rendered by an out-of-network (OON) 
provider from August 13, 2022, through October 25, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on August 13, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you are requesting reconsideration of the 
overpayment audit findings for the services performed on November 27, 2021. The Plan denied your request. 
The Plan says the overpayment refund request for ambulance services was rendered on August 13, 2020 is 
correct. The provider should submit the claim to Original Medicare for reconsideration. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated.  
The enrollee ended Medicare Hospice benefits on August 13, 2020. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance services 
provided on August 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on November 14, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you are allowed two cleanings and this is your 
second cleaning that you are requesting. 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 requested item or service was exhausted on date of service July 26, 2022. Therefore, 
we decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on November 14, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids purchased on August 8, 
2022. 
 
You asked the Plan to issue reimbursement 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 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 coverage is provided for 
hearing aids purchased through the Plans select hearing aid provider. However, 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 purchased on August 8, 2022.