Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulation (G0283) provided January 21, 2021 to 
August 19, 2021. 
 
You asked the Plan to pay for the chiropractic service. You say that you would like to appeal the refusal of 
payment. Even though this provider is not in network the Plan has to pay for basic manipulations. The Plan 
denied your request. The Plan says this service is not covered when rendered by a chiropractor. 
 
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 records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for electrical stimulation (G0283) provided January 21, 2021 to August 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120) provided on October 26, 2021. 
 
You asked the Plan to pay for the dental service. You say that this was not a dental procedure. You say that it 
should be handled under your medical coverage. You say that this exam was required prior to surgery. You 
also say that you cannot afford to pay this bill. The Plan denied your request. The Plan says 2 oral exams are 
covered per calendar year. The Plan also says that the frequency limit has been exceeded. 
 
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 and oral exams are covered, the 
frequency limit has been exceeded. The record shows that the Plan paid for oral exams that you received on 
April 27, 2021, and May 12, 2021. Therefore, we decided that the Plan does not have to pay for the oral exam 
(D0120) provided on October 26, 2021.  
 
Your complaint about how the service was billed is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on September 20, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for these 
services is included in the facility payment. 
 
Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for 
services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the 
beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to 
these services would have been included under the facility claim. Therefore, we decided that the Plan does not 
have to pay for the services provided on September 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for IV tubing extension set (CPT code S1015) and infection
control supplies (CPT code S8301) provided on August 16, 2021.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your
request. The Plan says the services are not covered as 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.
CPT code(s): S1015 and S8301 have a status code "I" Not valid for Medicare purposes. Medicare uses another
code for reporting of and payment for these services. 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 IV tubing extension set (CPT code S1015) and
infection control supplies (CPT code S8301) provided on August 16, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services (90832) provided on September 23, 
2021. 
 
You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's 
attending or primary care physician. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy services have not been met. Specifically, the provided records do not document an 
attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we 
decided that the Plan does not have to pay for psychotherapy services (90832) provided on September 23, 
2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on September 18, 2021. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. 
The Plan says per the Medicare Benefit Policy Manual, Chapter 10, Section 10.2.6, if no transport of a 
Medicare beneficiary occurs, then there is no Medicare-covered service. 
 
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 September 18, 2021. 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 ambulance response and treatment, no transport 
(A0998) provided on September 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) provided October 19, 2021. 
 
You asked the Plan to pay for the comprehensive oral exam. You say that you were in pain and needed an 
exam. The Plan denied your request. The Plan says you have exceeded the frequency limit for this service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the 
comprehensive oral exam once every three plan years. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive 
exam was previously covered on July 7, 2021. Based on this information, we decided that the Plan's frequency 
limit for coverage of the comprehensive oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided October 19, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services (CPT code(s): 81225, 81226, 81232, 81350, 
81306, 81283, 81231, 81247, 81328, 81335, and 81381) provided on June 1, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says that the services are not supported by the records. 
 
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 does not substantiate why these laboratory services are not supported. 
The reason the Plan gave was the place of service on the CMS-1500 form line 24B must reflect the location of 
the patient when the specimen was obtained. This should be overturned because the Plan paid for other 
laboratory services that were identically billed as the services the Plan has denied. Therefore, we decided that 
the Plan has to pay for the laboratory services (CPT code(s): 81225, 81226, 81232, 81350, 81306, 81283, 
81231, 81247, 81328, 81335, and 81381) provided on June 1, 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 pre-approve full mouth debridement to enable a comprehensive oral 
evaluation and diagnosis on a subsequent visit (D4355). 
 
You asked the Plan to pre-approve full mouth debridement. You say that you have not had any type of dental 
cleaning or other care that should be in conflict with this service in over five years. The Plan denied your 
request. The Plan says you had a previous comprehensive oral evaluation (D0150) provided on June 24, 2021. 
The requested service cannot be approved within one calendar year of an evaluation (D0120, D0150). 
 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 Plans contract states that 
full mouth debridement only covered when there is substantial gingival inflammation (gingivitis) in all four 
quadrants. It is not allowed for one calendar year following any of D1110 or D1120 or any D4000 series code. 
It cannot be performed on the same day or less than one calendar year after an evaluation (D0120, D0150).  
 
We looked at the file and the Plan's rules. Documentation shows that you had a comprehensive oral evaluation 
less than one calendar year before the request for a full mouth debridement (D4355). Based on this information, 
we decided that the Plan's rules for coverage of full mouth debridement have not been met. Therefore, we 
decided that the Plan does not have to pre-approve full mouth debridement to enable a comprehensive oral 
evaluation and diagnosis on a subsequent visit (D4355).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis 5MG tablet.
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied your request. The Plan says Eliquis is a self-administered drug and does not fall under Part B coverage.
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 Eliquis 5MG tablet.
Benefits for the medication 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies rendered on April 22, 2021.
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 are not covered.
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified and no payment is made for codes with a status indicator of P.
We looked at the file and Medicare rules. Billed procedure code 99072 (special supplies and materials) has a status indicator of B and no separate Medicare payment. Code A4557 (lead wires, pair) has a status indicator of P and no Medicare payment. Therefore, we decided that the Plan does not have to pay for the supplies rendered on April 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of the Intracept procedure in 
the setting of chronic low back pain has not been demonstrated in the peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The Intracept 
procedure is experimental. More research is needed. Our physician reviewer found that the enrollee's condition 
does not meet criteria for coverage of these services. 
 
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 pre-approve the Intracept procedure for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure code 0242U) provided to the 
enrollee on June 1, 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 Healthcare Common Procedure Coding System (HCPCS) code 0242U 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 0242U is "Targeted genomic sequence analysis panel, 
solid organ neoplasm, cell-free circulating DNA analysis of 55-74 genes, interrogation for sequence variants, 
gene copy number amplifications, and gene rearrangements." 
 
We find that CPT code 0242U is not supported in the medical record. Specifically, the place of service on the 
CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a 
place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's 
office (POS 11).  
 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 laboratory services (procedure code 0242U) 
provided to the enrollee on June 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) provided on 
November 18, 2021. 
 
You asked the Plan to pay for the first intraoral periapical x-ray. You say that your understanding is that you 
are eligible for one free preventive set of dental x-rays per calendar year. You also say that you had not yet had 
these x-rays and thought the first intraoral periapical x-ray would qualify. The Plan denied your request. The 
Plan says this service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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. The only types of x-rays covered under your plan are full mouth series, 
bitewing x-rays, or panoramic. Therefore, we decided that the Plan does not have to pay for the first intraoral 
periapical x-ray (D0220) provided on November 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on November 16, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you have been going to this doctor and location for 
over 10 years and now the Plan wants a referral from your primary doctor. You also say you do not understand 
what has changed. The Plan denied your request. The Plan says this provider is not a network provider with the 
Plan, and they have also determined that these services are not urgent or emergent, nor were they approved in 
advance. The Plan also says that there is not a referring provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit (99214) provided on November 16, 
2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro 2 Motion G Orthotic Device for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the clinical value and effectiveness of a MyoPro orthotic device in the setting 
of upper extremity partial paralysis secondary to cerebrovascular accident has not been demonstrated in the 
peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Current clinical 
guidelines designate robotic therapy to be of "uncertain utility compared with dose-matched conventional upper 
limb exercise therapies" with unproven benefit in the home environment. In addition, provided records 
document shoulder subluxation and left sided muscle spasticity which may be contraindications to use of the 
device.  
 Although records from the device vendor argue medical necessity of the requested device, no records from the 
enrollee's actual treating provider address the requested device or clarify why it is the most appropriate 
treatment for the enrollee's condition. Our physician reviewer found that the enrollee's condition does not meet 
criteria for coverage of these services. 
 
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 pre-approve a MyoPro 2 Motion G Orthotic Device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a stent placement (92929) provided on December 29, 2020.
You asked the Plan to pay for a stent placement. You say that this is supported in the records. The Plan denied your request. The Plan says this is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that a Medicare Physician Fee Schedule Database (MPFSDB) Status Indicator of B indicates that payment for covered services is always bundled into payment for other services not specified.
We looked at the file and Medicare rules. Code 92929 has a status indicator of B and is not separately payable. Based on this information, we decided that Medicare rules for coverage of a stent placement have not been met. Therefore, we decided that the Plan does not have to pay for a stent placement (92929) provided on December 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99212) provided on May 7, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that authorization is not required for an office visit. The 
Plan denied your request. The Plan says the unauthorized services rendered were by a non-participating 
provider. The Plan also says that it was determined that the services received were not urgent/emergent, and the 
member does not have out of network coverage for services determined to be non-urgent/emergent. 
 
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 office visit (99212) provided on May 7, 2021, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office services (CPT code 99214) provided to the 
enrollee on April 9, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for the out-of-network services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says service(s) provided requires prior authorization for non-contracted 
providers and in this case, no authorization has been 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 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 the office services (CPT code 99214) provided to 
the enrollee on April 9, 2021, by an out-of-network provider.