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

 
We decided that the Plan does not have to pay for surgical assistant services on shoulder surgery (29828, 
29826, 29823) provided on August 3, 2021. 
 
You asked the Plan to pay for surgical assistant services. You say that this should be covered as in-network. 
The Plan denied your request. The Plan says these services are not covered for the provider at issue. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services on 
shoulder surgery (29828, 29826, 29823) provided on August 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the screening digital breast tomosynthesis, bilateral (77063) 
and the screening mammography, bilateral (77067) rendered by the out-of-network (OON) provider on 
December 29, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the screening digital breast tomosynthesis, bilateral (77063) and the screening 
mammography, bilateral (77067) rendered by the out-of-network (OON) provider on December 29, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for outpatient mental health
services with a licensed professional counselor.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this request is a benefit exclusion.
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are
enrolled in the Medicare program.
The requested provider is not eligible to bill Medicare. We found no exception that would require the plan to
pre-approve these items/services. A licensed professional counselor is not considered a valid Medicare
provider. Based on this information, we decided that Medicare rules for coverage of the services have not been
met. Therefore, we decided that the Plan does not have to pre-approve an out-of-network referral for outpatient
mental health services with a licensed professional counselor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management (99239) provided on 
January 22, 2021. 
 
You asked the Plan to pay for hospital discharge day management (99239). You say that the professional 
service was rendered in good faith, and you request that payment be processed. The Plan denied your request. 
The Plan says procedure 99239 has previously paid and only one hospital discharge service is allowed per stay. 
 
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 99239 is hospital discharge day management; more than 
30 minutes. 
 
  We find that CPT code 99239 is not supported in the medical record. Specifically, a hospital discharge 
management service was already billed and paid for this date of service. Based on this information, we decided 
that Medicare rules for coverage of hospital discharge day management (99239) have not been met. Therefore, 
we decided that the Plan does not have to pay for hospital discharge day management (99239) provided on 
January 22, 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 January 
8, 2022. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that you should not be charged a 
specialist copayment since your PCP was not available at the time. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing amount. 
 
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 each specialist visit.  
 
You have been asked to pay a $40 copayment for the specialist visit. The specialist visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a specialist office visit provided on January 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), intraoral imaging 
(D0330), panoramic imaging (D0330), and 2D oral imaging (D0350) provided by a participating provider on 
December 2, 2021. 
 
You asked the Plan to pay for a comprehensive oral evaluation, intraoral imaging, panoramic imaging, and 2D 
oral imaging. You say that you would like the reprocessed to reflect no responsibility on my end. The Plan 
denied your request. The Plan says the benefit limit for D0210, D0150, D0330 has already been exhausted. The 
Plan say that D0350 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. The Plan covers a 
comprehensive oral evaluation once every three years, intraoral imaging and panoramic imaging once every 
five years. 2D oral imaging is not a covered dental benefit. We looked the file and Medicare rules. Evidence 
was provided to show that D0150, and D0210 were provided on March 22, 2019. Based on this information, 
we decided that the Plan's rules for coverage of a comprehensive oral evaluation, intraoral imaging, panoramic 
imaging have already been met. 2D oral imaging is not a covered benefit. Therefore, we decided that the Plan 
does not have to pay for a comprehensive oral evaluation (D0150), intraoral imaging (D0330), panoramic 
imaging (D0330), and 2D oral imaging (D0350) provided by a participating provider on December 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a nuclear medicine study of heart muscle 
provided on November 19, 2021. 
 
You asked the Plan to waive the copayment for a nuclear cardiac test. You say that due to having a pacemaker 
your grandfather is unable to do standard stress test. You also say it is not possible for him to afford $150 based 
on his fixed income. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The contract with the Plan clearly says that the enrollee must pay a 
$150 copayment for a nuclear cardiac imaging test.  
 
 The enrollee has been asked to pay a $150 copayment for a nuclear medicine study. A nuclear medicine study 
falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 nuclear medicine study of heart muscle provided on 
November 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the goniotomy (65820) provided on October 25, 2021. 
 
You asked the Plan to pay for the goniotomy (65820). You say that you are appealing the denial with attached 
medical records. The Plan denied your request. The Plan says codes 66174 and 66984 are not appealable and 
are being handled as first-level claim review. The Plan also says that code 65820 is denied as an appropriate 
modifier was not billed with the code edit. 
 
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 65820 
is a column II code to column I code 66174. 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 the goniotomy (65820) provided on October 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation provided on July 13, 2021. 
 
You asked the Plan to pay for the limited oral evaluation. You say that you weren't notified by the clinic that 
you didn't have enough funds and you don't have enough money to pay the bill. The Plan denied your request. 
The Plan says your dental maximum of $1,000 has already been met. 
 
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, you also have an annual maximum of 
$1,000 for covered dental services. The Plan paid $1,000 for dental services provided on March 15, 2021, May 
4, 2021, and June 3, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to 
pay for the limited oral evaluation provided on July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) provided on January 17, 2022. 
 
You asked the Plan to pay for the core buildup. You say that this service was necessary for your crown, and 
you feel it should be covered. The Plan denied your request. The Plan says this service is not covered by your 
dental benefit. 
 
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 the core 
buildup (D2950) provided on January 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the intraoral - periapical first 
radiographic image (D0220) and limited oral evaluation - problem focused (D0140) provided February 16, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to provide additional payment for the intraoral x-ray and limited oral exam. You say that 
you would like these services covered. The Plan denied your request. The Plan says these services have been 
correctly processed according to your OON benefits. 
 
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 intraoral 
x-ray and limited oral exam with 50% coinsurance when provided OON. When services are provided OON you 
may be billed by the OON provider for any amount greater than the payment made by the Plan to the provider. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that you were asked to 
pay 50% of the allowed amount for the intraoral x-ray and limited oral exam. Additionally, you may be 
responsible for the difference between the Plan's contracted rate and the total cost charged by the OON 
provider.  Therefore, we decided that the Plan does not have to provide additional payment for the intraoral - 
periapical first radiographic image (D0220) and limited oral evaluation - problem focused (D0140) provided 
February 16, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the porcelain crowns (D2740 x 2) and core build 
up (D2950 x 2) provided on December 1, 2021. 
 
You asked the Plan to reimburse you for the dental services. You say that you need this crown. You say that the 
crown is medically necessary. You also say that you cannot pay any more money. The Plan denied your 
request. The Plan says 2 crowns are covered per calendar year with a 70% coinsurance when received in 
network. The Plan also says that core build up is not listed as covered. 
 
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 and 2 crowns are covered per calendar 
year, there is a 70% coinsurance that applies when received in network. Additionally, core build up is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for 
the porcelain crowns (D2740 x 2) and core build up (D2950 x 2) provided on December 1, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 11, 2021. 
 
You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for laboratory services provided on August 11, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crisis psychotherapy session provided on January 5, 2022. 
 
You asked the Plan to pay for a crisis psychotherapy session. You say that the services were medically 
necessary and should be paid. The Plan denied your request. The Plan says this service is not covered as the 
provider is a social worker and not eligible for payment by the health Plan or Original Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a Masters of Social Work is not 
eligible to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Masters of Social Work. 
Medicare says that a Masters of Social Work is not eligible to participate in the Medicare program. Therefore, 
we decided that the Plan does not have to pay for a crisis psychotherapy session provided on January 5, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a third level facet joint injection. 
 
You asked the Plan to pre-approve a third level facet joint injection. You say that the requested third level facet 
joint injection is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested third level facet joint injection. 
 
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 a third level facet joint injection. Our 
reviewer says that the enrollee does not meet criteria for the requested third level facet joint injection. Our 
physician reviewer found the enrollee is with a history of chronic low back pain. The pain is worse with 
movement and is rated 10/10 at worst. On physical exam, the back range of motion is limited due to pain and is 
worse with extension and rotational stress of the facet joints. She has tried medical therapy with NSAIDs. The 
provider is recommending injection at L3-L4, L4-L5, L5-S1. 
 
According to the coverage criteria: One to two levels, either unilateral or bilateral, are allowed per session per 
spine region. The need for a three or four-level procedure bilaterally may be considered under unique 
circumstances and with sufficient documentation of medical necessity on appeal. A session is a time period, 
which includes all procedures (i.e., MBB, IA, facet cyst ruptures, and RFA ablations) that are performed during 
the same day. The review has determined that the requested 3rd level facet joint injection is not medically 
reasonable and necessary 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 a third level facet joint injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a third level facet joint injection.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hot or cold packs therapy (97010) provided on November 29, 2021. 
 
You asked the Plan to pay for hot or cold packs therapy. You say that there is a prior authorization for the 
physical therapy services on file with the Plan. The Plan denied your request. The Plan says the payment for 
this service is always bundled into payment for another service. 
 
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 97010 has a 
status indicator of B on the Physician Fee Schedule. This means that CPT 
code 97010 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of hot or cold packs therapy have not been met. Therefore, we decided that the Plan does not have to pay for 
hot or cold packs therapy (97010) provided on November 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) and the infrared 
therapy service (97026) rendered by the out-of-network (OON) provider on November 26, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the acupuncture treatment (97810, 97811) and the infrared therapy service 
(97026) rendered by the out-of-network (OON) provider on November 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 16, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on July 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia procedure (99135) provided on March 
25, 2021. 
 
You asked the Plan to pay for the special anesthesia procedure (99135). You say that the medical records are 
attached, and the claim should be reprocessed. The Plan denied your request. The Plan says procedure code 
76942 has been overturned and procedure code 99135 remains denied as bundled services are not eligible for 
separate reimbursement.  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 99135 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99135 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the special anesthesia procedure (99135) have not been met. Therefore, we decided that the Plan does not 
have to pay for the special anesthesia procedure (99135) provided on March 25, 2021.