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

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 
24, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. 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 September 24, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service November 
23, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the claim was billed correctly and should be 
paid. 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 for the HCPCS/CPT code will be denied.  
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service November 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for periodic oral evaluation (D0120) and 
prophylaxis (D1110) provided by January 5, 2023. 
 
You asked the Plan to waive the coinsurance for dental services. You say that the amount allowed is too low 
and the insurance company did not consider high rate of inflation. The Plan denied your request. The Plan says 
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 20% 
coinsurance of the total cost for each non-Medicare-covered dental services plus additional cost up to the 
provider billed amount for periodic oral evaluation (D0120) and prophylaxis (D1110) when provided by an 
out-of-network provider. 
  You have been asked to pay $27.40, which is 20% of the allowed amount for oral evaluation (D0120) and 
prophylaxis (D1110). The allowed amount is $137 (20% x $137 = $27.40). Oral evaluation (D0120) and 
prophylaxis (D1110) falls within the Out-of-Network 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 periodic oral evaluation (D0120) and prophylaxis (D1110) provided by January 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the mileage limit extension. 
 
You asked the Plan to pre-approve the mileage limit extension. You say that you would like the benefit to 
cover transportation over 50 miles for an appointment with your urologist. The Plan denied your request. The 
Plan says the service is not a covered benefit. 
 
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 30 miles per one-way trip trips per 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. Specifically, the trip 
requested is beyond the 30 miles per one-way trip. Therefore, we decided that the Plan does not have to pre-
approve the mileage limit extension.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hip orthosis with addition and cervical collar rendered on 
October 24, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has diagnoses of unilateral 
primary osteoarthritis of the right and cervicalgia. The clinical office visit note does not include documentation of a physical exam of the right hip or neck; therefore, the medical necessity of the services at issue is not 
supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the hip orthosis with addition and cervical collar rendered on October 24, 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 
October 27, 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 October 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital services provided from  
January 22, 2022, through January 28, 2022, at the Diagnosis Related Group (DRG) 871 originally billed. 
 You asked the Plan to pay for the acute inpatient hospital services at the DRG 871 originally billed. You say 
that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The 
Plan says the clinical evidence provided does not support the diagnosis code indicated. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code A40.3, defined as Sepsis due to 
Streptococcus pneumoniae and with the secondary diagnosis code R65.20 defined as severe sepsis without 
sepsis shock. We asked our physician reviewer to carefully review the case file and apply the relevant 
Medicare rules to determine if the Plan was correct in denying the request to pay for the acute inpatient hospital 
services at the DRG 871 originally billed. Our reviewer says that the acute inpatient hospital care provided was 
not billed correctly. Our physician reviewer found that the enrollee was transferred from an outside hospital for 
leukocytosis and pneumonia with complaints of several days of generalized weakness and cough. The 
laboratory services provided were notable for leukocytosis. The urinalysis only showed trace leukocytes and 
the computed tomography (CT) scan showed right-sided pneumonia. The enrollee was treated with Rocephin, 
Zithromax, and intravenous fluids before transfer and was started on broad-spectrum therapy with 
Vancomycin, Ceftriaxone, and Azithromycin. The enrollee was admitted with acute respiratory failure with 
hypoxia secondary to pneumonia. The blood culture had positive streptococcus pneumoniae in the blood stream 
and the Methicillin-resistant Staphylococcus aureus (MRSA) polymerase chain reaction (PCR) test was 
positive but likely normal colonization as the enrollee responded well with a deescalated antibiotic. In this case 
there was no clinical or laboratory evidence of sepsis. The review has determined that the documentation did 
not support diagnosis code A40.3, Sepsis due to Streptococcus pneumoniae and secondary diagnosis severe 
sepsis without septic shock (R65.20). The record supports DRG 189. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the acute inpatient hospital services provided from January 22, 2022, through January 28, 2022, at the 
Diagnosis Related Group (DRG) 871 originally billed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on August 30, 
2022. 
 
You asked the Plan to pay for dental services. You say that you do not agree with the requested treatments not 
being covered because you needed them for periodontal disease. The Plan denied your request. The Plan says 
the denial of payment for these services is correct, because this provider has opted out of Medicare and is not 
eligible for payment. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
periodontal maintenance (D4910) provided on August 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodontal maintenance (D4910) provided on November 
7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to make an exception. 
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 January 24, 2022, April 
28, 2022, and August 5, 2022. Therefore, we decided that the Plan does not have to pay for a periodontal 
maintenance (D4910) provided on November 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implant services. 
 
You asked the Plan to pre-approve the dental services. You say that this dental work is medically necessary. 
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 dental annual maximum amount has already been met. Therefore, we decided that the Plan does not 
have to pre-approve dental implant services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on July 17, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport provided. You say that 
you called 911 and you are not sure why the ambulance services came to the scene. The Plan denied your 
request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 17, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on July 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2740) and core build-ups (D2954). 
 
You asked the Plan to pre-approve crowns and core build-ups. You say that you believe this should be covered 
100%. The Plan denied your request. The Plan says the requested dental services are not covered 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. 
 
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 pre-approve 
crowns (D2740) and core build-ups (D2954).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam computed tomography (CT) scan (D0367)) 
provided on November 22, 2022. 
 
You asked the Plan to pay for the CT scan. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall within 
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. 
 
 
  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 cone 
beam computed tomography (CT) scan (D0367)) provided on November 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aid evaluations (92593 x 2) 
provided on November 8, 2022 and December 8, 2022. 
 
You asked the Plan to issue reimbursement 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 these services are 
not payable as they were rendered by 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.  
 
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 services have not been met. Specifically, the Plans contract states that coverage is provided 
for hearing aids/services obtained only through the Plans select hearing aid provider. However, the hearing aid 
evaluations in this case were rendered by an out-of-network provider. Therefore, we decided that the Plan does 
not have to issue reimbursement for the hearing aid evaluations (92593 x 2) provided on November 8, 2022 and 
December 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the 
Plan only allows out-of-network care in the setting of emergencies, urgently needed services when the network 
is not available, out-of-area dialysis services and cases in which the Plan authorizes use of out-of-network 
providers. None of these scenarios apply to this members request. We confirmed there are two in-network 
providers whose locations are all less than 45 minutes and 30 miles from the members home. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses (V2020, V2103, V2750, V2799) received from 
August 4, 2022, through August 26, 2022, from an out-of-network provider. 
 You asked the Plan to pay for eyeglasses. You say that you want the Plan to reimburse you the charges. The 
Plan denied your request. The Plan says services received out-of-network are not covered. Additionally, the 
routine eyeglass benefit is available every two years. 
 
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 you utilize 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 eyeglasses have not been met. The provider is out-of-network. Additionally, you received 
eyeglasses on July 8, 2021, and they are only covered once every two years. Therefore, we decided that the 
Plan does not have to pay for eyeglasses (V2020, V2103, V2750, V2799) received from August 4, 2022, 
through August 26, 2022, from an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261 x 2) purchased on 
September 10, 2021. 
 
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 rendered by 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 this 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 (V5261 x 2) purchased on September 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel (87798, 
87481) provided on May 6, 2022. 
 
You asked the Plan to pay for the urine PCR panel. You say that this claim should be covered. The Plan denied 
your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. This was a 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 urine PCR panel have 
not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction 
(PCR) panel (87798, 87481) provided on May 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97810, 97811) provided on 
November 8, 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 these services are not payable as they were 
rendered by an ineligible provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the acupuncture treatments (97810, 
97811) provided on November 8, 2022.