Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for reline of complete lower denture (D5751) provided on 
October 10, 2022. 
 
You asked the Plan to pay for the dental service. You say that the dental procedure was necessary because the 
denture was causing pain in your mouth. 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 complete lower denture was paid on date of service May 18, 2022, therefore, the reline of the 
complete lower denture was within the 6 months of initial placement. Therefore, we decided that the Plan does 
not have to pay for reline of complete lower denture (D5751) provided on October 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cervical, multiple post collar, occipital/mandibular supports, 
adjustable provided to the enrollee on September 29, 2022. 
 
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 the documentation submitted did not sufficiently support the billed supply code. 
 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the records do not properly describe the need for an occipital-cervical stabilization orthotic. More 
information is needed to justify the clinical use of this orthotic 
 
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 pay for cervical, multiple post collar, occipital/mandibular supports, adjustable provided to the enrollee 
on September 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J2001 billed for date of service May 9, 2022. 
 
You asked the Plan to pay for procedure code J2001. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code J2001 is bundled into 
payment for code 20610. 
 
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 J2001 
is a column II code to column I code 20610. 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 J2001 billed for date of service May 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and an intraoral 
radiographic image (D0210) provided by an out-of-network provider on October 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider told you they were in-network, and 
you would like the dental services covered. The Plan denied your request. The Plan says the periodic oral 
evaluation was received from an out-of-network provider and is not covered by your supplemental benefits. 
Also, the denial of payment for intraoral radiographic image is correct, because it is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  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 periodic oral evaluation is not covered under this 
benefit when received from an out-of-network provider. The intraoral radiographic image is not covered under 
the Plans dental benefit in-network or out-of-network. Therefore, we decided that the Plan does not have to 
pay for a periodic oral evaluation (D0120) and an intraoral radiographic image (D0210) provided by an out-of-
network provider on October 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the out-of-network lab services provided on 
August 6, 2021. 
 
You asked the Plan to waive the cost share for the lab services. You say that the labs should be processed as in-
network. 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 a 30% 
coinsurance after the deductible is met for out-of-network diagnostic lab services.  
 The Plan has confirmed that the lab where the services were provided is out-of-network with the Plan. You 
have been asked to pay $112.50 for the lab services. The services fall within the outpatient diagnostic tests 
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 cost share for the out-of-network lab services 
provided on August 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on May 
11, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you do not agree with the 
cost sharing applied to this service. 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 a $40 
copayment for services obtained from a specialist in a specialists office. 
 
You have been asked to pay a $40 copayment for a specialist office visit. This item/service falls within the 
services obtained from a specialist in a specialists office 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 copayment for a specialist office visit provided on May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the disposable contact lenses (S0500) purchased on March 3, 
2022, from an out-of-network (OON) provider. 
 
You asked the Plan to pay for the disposable contact lenses. You say that the provider you purchased the 
contact lenses from was not OON. You also say that you purchased through the same place in 2021, and they 
were covered. The Plan denied your request. The Plan says the disposable contact lenses are not covered 
because they were purchased from a provider that is outside of the Plan's network of providers, and prior 
authorization was not 
obtained. The claim does not meet the urgent or emergent criteria, and there is no documentation that you were 
referred to this non-contracted provider by a contracted provider. 
 
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 use a doctor in the Plan's vision network. 
 
 
 
 We looked at the file and the Plan's rules. Specifically, the record shows that you obtained these contact lenses 
from an OON provider. Based on this information, we decided that the Plan's rules for coverage of the 
disposable contact lenses have not been met. Therefore, we decided that the Plan does not have to pay for the 
disposable contact lenses (S0500) purchased on March 3, 2022, from an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for internal medicine services provided on October 28, 2022. 
 
You asked the Plan to pay for internal medicine services. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for internal medicine 
services provided on October 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services provided on September 27, 
2022. 
 
You asked the Plan to waive the copayment for lab services. You say that you do not agree with the cost 
sharing amount. 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 a $40 
copayment for in-network lab services provided in an outpatient hospital facility. 
 
You have been asked to pay a $40 copayment for lab services. This item/service falls within the in-network lab 
services provided in an outpatient hospital facility 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 
copayment for lab services provided on September 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electroencephalogram (EEG); recording in coma or sleep 
only provided to the enrollee on April 7, 2022. 
 
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 Current Procedural Terminology (CPT) code 95822 26 (1 unit) 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 95822 is "Electroencephalogram (EEG); recording in 
coma or sleep only." 
 
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 not supported by the medical records. Our reviewer found that the enrollee was being treated for 
intervertebral disc displacement of the lumbar region; radiculopathy of the lumbar region; and 
spondylolisthesis of the lumbar region. He underwent a decompression L4-5, laminectomy L4-5, lateral fusion 
L4-5, and lumbar interbody fusion at L4-5 on 4/7/22. The technical report did corroborate that an electroencephalogram (EEG) was performed during the procedure. However, this code is not specifically 
supported as the enrollee was not in a coma or sleep. There are typically more appropriate codes to use for the 
clinical situation presented in this case. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for electroencephalogram (EEG); recording in coma or sleep only provided to the enrollee on April 
7, 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 this claim denied as a duplicate in error. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services (procedure code 99223) provided 
to the enrollee on April 25, 2022. 
 
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 the documents do not support the level of care. 
 
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 care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit." 
 
We asked our 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 services. Our reviewer says that the services at issue 
in this case were not supported by the medical records. Our reviewer found that the review has determined that 
the records did not support that CPT 99223 was rendered in this case. The records did not support 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient hospital services (procedure code 99223) provided to the enrollee on April 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on October 4, 2022. 
Additionally, the Plan does not have to waive the copayment for the chiropractic manipulative treatment 
(98941) provided on October 4, 2022.  
 
 
 You asked the Plan to pay for the office visit. Additionally, you asked the Plan to waive the copayment for the 
chiropractic manipulative treatment. You say that you are requesting a reconsideration of the Plan's denial for 
payment. The Plan denied your request. The Plan says a chiropractic office visit is not a covered benefit. 
Additionally, the Plan says the copayment has been applied correctly to the chiropractic manipulative treatment 
provided.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 
copayment for in-network Medicare covered chiropractic services.  
 
The records show that the office visit provided in this case is not a covered benefit by Medicare or the Plan. 
Additionally, you were asked to pay a $20 copayment for the in-network Medicare covered chiropractic service 
provided. 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 pay for the office visit (99202) provided on October 4, 2022. 
Additionally, the Plan does not have to waive the copayment for the chiropractic manipulative treatment 
(98941) provided on October 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrodes (A4556) provided on October 7, 2022. 
 
You asked the Plan to pay for the electrodes. You say that this item was medically necessary. The Plan denied 
your request. The Plan says the documentation does not support the billed service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order which supports medical necessity for the supplies provided 
in this case. Outreach by the plan to the attending physician has confirmed this item was not ordered. The 
record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for electrodes (A4556) provided on October 7, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee can still benefit from therapy services to 
continue to improve their overall health and independence. The Plan denied your request. The Plan says the 
enrollee no longer had SNF needs. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee did not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of fluoride (D1208) provided on September 
20, 2022. 
 
You asked the Plan to pay for the dental service. You say that the dental service is covered by the Plan. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because the 
application of fluoride was not covered by the Plan in the year of 2022. 
 
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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
application of fluoride (D1208) provided on September 20, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 
You asked the Plan to pre-approve Synvisc. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says not tried and failed one of the preferred step therapies (multi-injection) 
device(s): Orthovisc OR Supartz FX. The Plan also says there is no indication their preferred agent(s) would 
likely be less effective, and/or cause adverse effects for the member. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Synvisc. Our reviewer says that the 
enrollee does not meet the step therapy criteria. Our physician reviewer found there is no indication that the 
enrollee has tried and failed the required drug(s). Our physician reviewer also found that there is no indication 
that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc.