Persius/hicric huggingface dataset:
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 
December 15, 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 December 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87507) provided on December 2, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 the lab services have been met. No 
clinical records were submitted to support this service. Only lab results were provided. Therefore, we decided 
that the Plan does not have to pay for lab services (87507) provided on December 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on December 7, 2022. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 codes 76642, 77065, and G0279 are ultrasound, breast, 
unilateral, real time with image documentation, including axilla when performed; limited, diagnostic 
mammography, including computer-aided detection (CAD) when performed, unilateral, and diagnostic digital 
breast tomosynthesis . 
 
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 imaging services provided. Our reviewer says that documentation does not support the billed codes. Our reviewer found the diagnosis reported for this service, is 
not coded to the highest specificity and therefore does not support service billed. 
 
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 imaging services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for imaging services provided on December 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on November 4, 2021. 
 
You asked the Plan to pay for the medical services. You say that this claim has been filed in a timely manner, 
and you would like it to be reprocessed towards payment. The Plan denied your request. The Plan says the 
claim was received on December 27, 2022. The Plan also says that this claim was processed and denied for 
untimely filing of claim. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
 The record shows that a claim for the medical services was not filed until December 27, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the medical services provided on November 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service provided on October 9, 2021. 
 You asked the Plan to pay for the ambulance service. You say that you are requesting a reconsideration stating 
the Plan needs to pay this claim. The Plan denied your request.  
 
The Plan says the Plan covers ambulance transportation only when you are actually transported by ambulance. 
Since you were not transported by this ambulance, the service is not covered under your plan. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for ambulance 
service provided on October 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on October 21, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for an OON x-ray. You say that this was medically necessary. The Plan denied your 
request. The Plan says this was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an x-ray provided on October 21, 2022, by an out-
of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited ultrasound scan behind abdominal cavity (76775-
26) provided on September 1, 2022. 
 
You asked the Plan to pay for the service. You say that the claim is coded correctly and should be paid. The 
Plan denied your request. The Plan says the primary diagnosis is inappropriate. 
 
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. Review of the file shows that claim 
was submitted with diagnosis code Z82.49-family history of certain disabilities and chronic diseases (leading to 
disablement). Diagnosis code Z82.49 is a family history code and not appropriate as a primary diagnosis. The 
rules say that the reason for the encounter (for example, screening or counseling) should be sequenced first and 
the appropriate personal and/or family history code(s) should be assigned as additional diagnos(es). Therefore, 
we decided that the Plan does not have to pay for the limited ultrasound scan behind abdominal cavity (76775-
26) provided on September 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OsteoStrong. 
 
You asked the Plan to pre-approve OsteoStrong. You say that the services are medically necessary. The Plan 
denied your request. The Plan says according to the Evidence of Coverage, OsteoStrong is not a covered 
service. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The Plans rules for coverage of gym benefits have not been met because OsteoStrong is not a covered health 
and wellness education program. Therefore, we decided that the Plan does not have to pre-approve 
OsteoStrong.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the specialist office visit provided on 
August 25, 2022. 
 
You asked the Plan to reduce the coinsurance for the specialist office visit. You say that the charges should be 
paid at an in-network benefit level. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% 
coinsurance for out-of-network physician/practitioner services, including doctors office visits.  
You have been asked to pay 50% coinsurance for the specialist office visit. This item/service falls within the 
out-of-network 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. The total you owe is $65.84 ($131.68 
allowed amount x 50% = $65.84). Therefore, we decided that the Plan does not have to reduce the coinsurance 
for the specialist office visit provided on August 25, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9500 billed for date of service August 9, 
2022. 
 
You asked the Plan to pay for procedure code S9500. You say that this service was medically necessary. 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 S9500 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9500 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9500 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9500 billed for date of service August 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99223) provided on August 10, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the codes billed. 
 
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 99223 is initial hospital inpatient care, per day, for the 
evaluation and management of a patient, which requires a comprehensive history, a comprehensive exam, and 
medical decision making of high complexity. 
 
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 physician services. Our reviewer says that the records do 
not support the code billed. Our reviewer found there was no documentation of a comprehensive history and medical decision making of high complexity. 
 
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 physician services have not been met. Therefore, we decided that the Plan 
does not have to pay for physician services (99223) provided on August 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on August 2, 
2022. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on 
August 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant/abutment supported removal denture (D6111). 
 
You asked the Plan to pre-approve implant/abutment supported removal denture. You say that this should be 
covered. The Plan denied your request. The Plan says this is not a covered service. 
 
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 
implant/abutment supported removal denture (D6111).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services provided on November 11, 
2022. 
 You asked the Plan to pay for the paramedic intercept services. You say that you feel the paramedic's services 
were needed at this time, and were requested by the emergency medical technicians. The Plan denied your 
request. The Plan says this service is not covered. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept services provided on November 11, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for endodontic therapy, anterior tooth (excluding final restoration) 
(D3310), prefabricated post and core in addition to crown (D2954), intraoral - periapical first radiographic 
image (D0220), cone beam CT capture and interpretation with limited field of view  less than one whole jaw 
(D0364), and consultation - diagnostic service provided by dentist or physician other than requesting dentist or 
physician (D9310) provided on July 5, 2022, to August 25, 2022. 
 
You asked the Plan to pay for the dental services represented by codes D3310, D2954, D0220, D0364, and 
D9310. You say that you are seeking coverage under the medical plan. The Plan denied your request. The Plan 
says that these services are purely dental in nature and cannot be covered under the medical plan. 
 
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 contract says it pays up to $2,500 every year for in-network and out-of 
network non-Medicare covered preventive dental services and non-Medicare comprehensive dental services 
combined. You are responsible for any amount above the dental coverage limit. Specifically, the Plan did not 
include any documentation to show or support the dental benefit maximum had been reached. This means the 
Plan did not substantiate their denial reason. Therefore, we decided that the Plan has to pay for endodontic 
therapy, anterior tooth (excluding final restoration) (D3310), prefabricated post and core in addition to crown 
(D2954), intraoral - periapical first radiographic image (D0220), cone beam CT capture and interpretation with 
limited field of view  less than one whole jaw (D0364), and consultation - diagnostic service provided by 
dentist or physician other than requesting dentist or physician (D9310) provided on July 5, 2022, to August 25, 
2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99204) provided on August 8, 2022. 
 
You asked the Plan to pay for the office visit. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the billed code is 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 CPT code. 
 
We find that CPT code 99204 is not supported in the medical record. Specifically, this service is included in the 
primary procedures that were billed on the same date and performed by the same provider (95886-RT, 95886-
LT and 95910). Based on this information, we decided that Medicare rules for coverage of the office visit have 
not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99204) provided on 
August 8, 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 
December 12, 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 December 12, 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  
July 29, 2022 and August 9, 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 July 29, 2022 and August 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on August 2, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound care supplies. You say that these supplies are separately payable. The 
Plan denied your request. The Plan says prior authorization was not obtained. 
 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 in this case is not a network provider with the Plan. 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 the wound care supplies provided on August 2, 2022, by an out-
of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) purchased on 
January 4, 2023. 
 
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 the hearing aids 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 through 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 Plan provides coverage for hearing aids only when 
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) purchased on January 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services with an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the dental services. You say that you want to go to this dentist because they 
are very good and you trust them. The Plan denied your request. The Plan says dental services from an out-of-
network provider 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. 
 
You are requesting 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 pre-approve dental 
services with an out-of-network (OON) provider.