Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Partially Favorable

 We decided that the Plan has to pay for the services. We decided that the Plan does not have to pay for 97026.  
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan says that the denied 
codes remain not supported. 
 
We decided that the Plan has to pay for 97814.  
 
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 CPT 97814 is "Acupuncture, 1 or more needles; with electrical 
stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of 
needle(s) (List separately in addition to code for primary procedure)." 
 
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 for CPT 97814. Our reviewer says that these services 
were supported by the medical records. Our physician reviewer found that for both dates of service, the 
services supported this denied code, and the amount of units billed. In regard to the units billed, there is 1 unit 
billed for each 15 minute therapy procedure. To cite the report: " Patient laid down and I proceeded to apply 4 
acupuncture needles in her glute/hip area. Applied electrical stimulation on the needles for 15 minutes. Then 
applied electrical stimulation to needles applied on her lateral epicondlye of her tibia for another 15 minutes. 
For another 15 minutes applied electrical stimulation to needles in the medial aspects of her ankles". In this 
case, 3 different areas received therapy, each 15 minutes; therefore, the units billed were appropriate. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
97814.  
 
We also decided that the Plan does not have to pay for 97026. 
 
The plan follows Medicare rules. The rules state that infrared therapy is not covered. 
 
The CPT definition of CPT 97026 is "application of a modality to 1 or more areas; infrared." 
  
The billed code represents a treatment modality that is statutorily not covered. Based on this information, we 
decided that Medicare rules for coverage of 97026 have not been met. Therefore, we decided that the Plan does 
not have to pay for 97026. 
 
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 waive the copayment for an extremity study ultrasound and a 
specialist office visit provided on October 25, 2021. 
 
You asked the Plan to waive the copayment for an ultrasound and a specialist office visit. You say that the 
provider's office told you the $25 was not due and now are receiving statements saying you owe the $25. 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 $25 
copayment for carotid or peripheral vascular ultrasounds. The Plan contract also says that enrollees must pay a 
$20 copayment for a specialist office visit. The contract also says that a separate physician office copayment 
may apply if other services are rendered at the time of the visit.   
 
The record shows this claim is approved, and you have a cost sharing amount for both services. You have been 
asked to pay a $25 copayment for an ultrasound. An ultrasound falls within the Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies benefit category. You have also been asked to pay a $20 copayment for a 
specialist office visit. You have been asked to pay a total of $45 ($25 copayment + $20 copayment = $45). A 
specialist office visit falls within the 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. Therefore, we 
decided that the Plan does not have to waive the copayment for an extremity study ultrasound and a specialist 
office visit provided on October 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on December 15, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that at the time of service, the member 
was residing at the facility and therefore, the rendering provider was not responsible to obtain authorization. 
You also say that the assisted living facility is responsible to obtain prior authorization for all of their patients, 
which should also cover for the medical treatment provided by the rendering provider. The Plan denied your 
request. The Plan says this provider is out-of-network with the Plan, and authorization was not obtained prior to 
the services being rendered. 
 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 a domiciliary or rest home visit provided on 
December 15, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound (76641) provided on 
November 17, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
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 $45 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $45 copayment for an ultrasound. Ultrasounds fall 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 an ultrasound (76641) provided on November 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power seat elevation system (CPT code E2300). 
 
You asked the Plan to pre-approve the item. You say that the item is necessary. The Plan denied your request. 
The Plan says the item is not covered. 
 
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 item have not been met. The rules say that a power seat 
elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily 
medical in nature. If a wheelchair has an electrical connection device described by code E2310 or E2311 and if 
the sole function of the connection is for a power seat elevation or power standing feature, it will be denied as 
non-covered. Therefore, we decided that the Plan does not have to pre-approve the power seat elevation system 
(CPT code E2300).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reduce the copayment for an office visit provided on August 24, 2021. 
 
You asked the Plan to reduce the copayment for office visit. You say that this should only be a $10 copayment 
because your primary care provider was unavailable. The Plan denied your request. The Plan says that the 
copayment amount you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay $10 copayment for each primary care visit.  
 
The Plan says you must pay $40 copayment for primary care office visit. Based on the Plan contract, however, 
you cannot be asked to pay more than $10 copayment for primary care office visit. Therefore, we decided that 
the Plan has to reduce the copayment for an office visit provided on August 24, 2021 from $40 to $10.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an ostomy belt provided on January 20, 
2022. 
 
You asked the Plan to waive the coinsurance for an ostomy belt. You say that your cost share has been $0 for 
the past three years. 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 20% 
coinsurance for in-network durable medical equipment.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
$6.07, which is 20% coinsurance of the allowed amount for an ostomy belt ($30.36 allowed amount x 20% coinsurance = $6.07). An ostomy belt falls within the Durable Medical Equipment (DME) and Related 
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 coinsurance for an ostomy belt provided 
on January 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve other accessories, side guards (K0108). 
 
You asked the Plan to pre-approve side guards. You say that the enrollee is physically and mentally capable of 
self-propelling in an ultra-lightweight wheelchair for short distances. The Plan denied your request. The Plan 
says this item does not serve a medical purpose is and is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this physician's review, the file, and Medicare rules. Wheelchair side guards are devices installed 
on the rear wheels to protect you from pebbles, splashes and debris as well as to keep things from being stuck in your chair. Side guards are only medically necessary for outdoor use and are therefore not covered. Based on 
this information, we decided that Medicare rules for coverage of side guards have not been met. Therefore, we 
decided that the Plan does not have to pre-approve other accessories, side guards (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinalysis services provided on July 8, 2021. 
You asked the Plan to pay for the services provided. You say that you were compliant with the requirements. 
The Plan denied your request. The Plan says an appropriate modifier was not 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, we have confirmed that code 81000 is a column II code to column I code G0483. This claim has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare rules 
for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the urinalysis 
services provided on July 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mastectomy bra provided on December 22, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for mastectomy bra. You say that you were told that you would be granted an 
exception to get the mastectomy bra. The Plan denied your request. The Plan says The denial of authorization 
for these services is correct. 
 
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 mastectomy bra provided on December 22, 2021 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the cost share for Technetium and a regadenoson injection provided on 
October 13, 2021. We also decided that the Plan does not have to reduce the cost share for a SPECT scan and a 
stress test provided on October 13, 2021. 
 
You asked the Plan to reduce the cost share for a SPECT scan, stress test, Technetium and a regadenoson 
injection. You say that you already paid the $110 copayment and are now being billed for additional charges. 
The Plan says that you have been charged the correct cost sharing amount. 
 
We decided that the Plan has to waive the cost share for Technetium (code A9502) and a regadenoson 
injection (J2785).  
 
The Plan says you must pay 20% coinsurance for Technetium (A9502) and a regadenoson injection (J2785). 
According to Medicare, these services are considered packaged codes and are not separately payable. 
Therefore, we decided that the Plan has to waive the cost share for Technetium and a regadenoson injection 
provided on October 13, 2021. 
 
We also decided that the Plan does not have to reduce the cost share for a SPECT scan (code 78452) and 
a stress test (code 93015). 
 
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 $110 
copayment for radiological diagnostic services, including SPECT scans. The Plan contract also says that 
enrollees must pay a $25 copayment for non-radiological diagnostic services, including stress tests.  
 
You have been asked to pay a $110 copayment for a SPECT scan. You have also been asked to pay a $25 
copayment for a stress test. A SPECT scan and a stress test fall 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 reduce the cost share for a 
SPECT scan and a stress test provided on October 13, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
October 25, 2021. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that the provider told you that if 
you received this bill you should send it to the Plan to take a look at. The Plan denied your request. The Plan 
says the copayment amount you are being charged is correct. 
 
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 $250 
copayment for each one-way covered ground ambulance trip.  
 
You have been asked to pay $250 copayment for ambulance transport. Ambulance transport falls within the 
Ambulance Services 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 ambulance 
transportation provided on October 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyaluronan injections to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says the service is 
available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
Hyaluronan injections to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of an impacted tooth (D7220) provided on 
December 2, 2021. 
 
You asked the Plan to pay for the removal of an impacted tooth. You say that you have dental coverage and 
you would like to know what the Plan does cover if they do not cover extractions. You also say that the claim 
might have denied due to the deep sedation, but your dentist is a specialist and is the best judge about safety for 
his patients. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 
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. 
 
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 
removal of an impacted tooth (D7220) provided on December 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code(s): 22869 and 22870). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says experimental and investigational procedures are not covered by Medicare. 
 
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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental. More research is needed. 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 pre-approve the Vertiflex 
superion device placement surgery (CPT code(s): 22869 and 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ninety-six (96) units of ostomy pouch liquid deodorant 
(A4394). 
 
You asked the Plan to pre-approve ostomy pouch liquid deodorant. You say that the items requested are 
medically necessary. The Plan denied your request. The Plan says Medicare covers 48 units every 90 days. The 
Plan also says that a review of the clinical record and outreach to the provider does not document/indicate the 
medical necessity of units in excess of what Medicare allows. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers 48 units every 90 days.   
 
While the ostomy pouch liquid deodorant may be appropriate in this case, Medicare covers 48 units in 90 days. 
The records also show that additional supplies are covered when medical records show a medical reason as to 
why the enrollee needs more that what is covered. Therefore, we decided that the Plan does not have to pre-
approve ninety-six (96) units of ostomy pouch liquid deodorant (A4394).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on October 15, 2021. 
 
You asked the Plan to pay for the dental service. You say that this service should be covered. You say that it 
was necessary since you were having issues with a previous procedure. The Plan denied your request. The Plan 
says the claim denied correctly. 
 
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 frequency limit has been exceeded. 
The record shows that the Plan covers 2 periodic or limited oral evaluations per calendar year. The record 
shows that the Plan paid for a limited oral evaluation that you received on January 13, 2021, and a periodic oral 
evaluation you received on May 20, 2021. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation (D0140) provided on October 15, 2021.