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

 
We decided that the Plan does not have to pay for procedure code(s) 88307 and 88313 billed for date of service 
September 15, 2022. 
 You asked the Plan to pay for procedure code(s) 88307 and 88313. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says these codes are included in the 
facility payment and are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88307 and 88313. 
This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88307 and 
88313. Based on this information, we decided that Medicare rules for coverage of procedure codes 88307 and 
88313 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code(s) 
88307 and 88313 billed for date of service September 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiologic examination; tibia and fibula, 2 views (x-ray) 
provided on December 21, 2022, billed with procedure code 73590. 
 
You asked the Plan to pay for the x-ray. You say that the services were medically necessary. The Plan denied 
your request. The Plan says the modifier appended to that line does not align with the laterality of the diagnosis 
it is pointed to. 
 
The Plan must follow Medicare rules. Medicare rules say that health plans, physicians, hospitals, and other 
health care providers must comply with the Official International Classification of Disease, 10th Edition, Clinical Modification (ICD-10-CM) Coding Guidelines.  
 
We looked at the file and Medicare rules. Diagnosis code M79.671 is specific to the right side and is not 
appropriate for lines with modifier LT (left) appended. Based on this information, we decided that Medicare 
rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for 
a radiologic examination; tibia and fibula, 2 views (x-ray) provided on December 21, 2022, billed with 
procedure code 73590.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental filling, maxillary and mandibular partial denture 
(D2392, D5211, D5212) provided on December 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the fillings has already been 
exhausted. Coverage for the partial dentures denied correctly as they were received after the prior authorization 
had expired. 
 
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 benefit for the requested item or service was exhausted on date of service August 8, 2022. The 
record indicates that the partial dentures were provided outside of the plans authorization period from July 29, 
2022 through October 27, 2022. Therefore, we decided that the services denied correctly. Therefore, we 
decided that the Plan does not have to pay for a dental filling, maxillary and mandibular partial denture 
(D2392, D5211, D5212) provided on December 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99417 billed for date of service August 31, 
2022. 
 
You asked the Plan to pay for procedure code 99417. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99417 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code 99417 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99417 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99417 billed for date of service August 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a golf cart (E1399). 
 
You asked the Plan to pre-approve a golf cart. You say that you need this item to get around. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a golf cart (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray, limited oral evaluation, and bitewing x-ray 
(D0220, D0140, D0270) provided on January 17, 2023, to February 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial and was misinformed. The Plan denied your request. The Plan says the dental services were 
received from an out-of-network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  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 requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for an intraoral x-ray, limited oral evaluation, and bitewing x-ray (D0220, D0140, D0270) provided on 
January 17, 2023, to February 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam computed tompgraphy (CT) scan (D0363) 
provided on November 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
   
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 a cone 
beam computed tompgraphy (CT) scan (D0363) provided on November 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11721 billed for date of service September 
14, 2022. 
 You asked the Plan to pay for procedure code 11721. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 11721 is bundled into payment for code 11055. 
 
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 11721 
is a column II code to column I code 11055. 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 11721 billed for date of service September 14, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92004) and eye refraction (92015) provided 
on November 30, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the eye exam and eye refraction. You say that the cost of the examination was 
$255.00. You also say that the Plan provided no information as to why the claim was being denied. The Plan 
denied your request. The Plan says these services were rendered by a provider who is not affiliated with either 
of the health systems. The Plan also says that you did not call prior to getting these services to confirm network 
status, and there was not extenuating circumstances to overturn the decision. 
 
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 they are rendered by an in-network provider. 
 We looked at the file and the Plan's rules. The record shows that you received these services from an OON 
provider. Based on this information, we decided that the Plan's rules for coverage of the eye exam and eye 
refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye exam 
(92004) and eye refraction (92015) provided on November 30, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the acupuncture treatment (97810) and the 
office visit (99202) provided on December 9, 2022. 
 
You asked the Plan to issue reimbursement 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 are 
not payable as they were rendered by an ineligible provider. 
 
 
 
 The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services in this case were not 
rendered under the supervision of a physician, physicians assistant, nurse practitioner, or clinical nurse 
specialist. Therefore, we decided that the Plan does not have to issue reimbursement for the acupuncture 
treatment (97810) and the office visit (99202) provided on December 9, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine transportation service provided on October 18, 2022. 
 
You asked the Plan to pay for the routine transportation. You are asking to please accept the submitted 
paperwork and reconsider payment for this claim. The Plan denied your request. The Plan says authorization is 
not on file for the routine transportation service. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when this benefit is provided by the Plans designated provider.  
 
We looked at your request, the records in the case file, and the rules. This transportation was not provided by 
the Plans designated provider. Based on this information, we decided that the Plans rules for coverage of 
routine transportation have not been met. Therefore, we decided that the Plan does not have to pay for routine 
transportation service provided on October 18, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on October 12, 2021. 
 
You asked the Plan to pay for the ambulance services. You ask to please accept the submitted paperwork and 
reconsider payment for this claim. The Plan denied your request. The Plan says the claim was not received 
within the allowed 12 months from the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the ambulance services was not filed until November 9, 2022. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for ambulance services provided on October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral hygiene instructions (D1330) provided on February 3, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 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 oral 
hygiene instructions (D1330) provided on February 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99225 billed for date of service August 8, 
2022. 
 You asked the Plan to pay for procedure code 99225. You say that you would like the Plan to reconsider their 
denial of payment. 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 cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 99225 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99225 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99225 billed for date of service August 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiologic examination, chest; single view (x-ray) provided 
on November 28, 2022, billed with procedure code 71045. 
 
You asked the Plan to pay for the x-ray. You say that the correct place of service was billed. The Plan denied 
your request. The Plan says the incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the Place of Service (POS) code assigned by the 
physician/practitioner for the professional component (PC) of a diagnostic service shall be the setting in which 
the enrollee received the technical component (TC) service.  
 
We looked at the file and Medicare rules. The claim reflects the 2-digit place of service (POS) code 22 for on 
campus-outpatient hospital. The member was registered as an inpatient of a hospital during the time of service. 
The appropriate inpatient POS code must be used. Based on this information, we decided that Medicare rules 
for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a radiologic examination, chest; single view (x-ray) provided on November 28, 2022, billed with procedure code 
71045.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 17, 2022. 
 
You asked the Plan to pay for lab services. You say that the lab testing was used for accuracy of infection. 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 lab services provided on 
May 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
28, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 
70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service December 28, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the limited oral evaluation (D0140), a cone beam 
(D0364), an extraction (D7210), excision of benign lesion (D7411), and deep sedation (D9222 and D9223) for 
tooth #5 provided by out-of-network providers on August 31, 2022, and October 27, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the services rendered were required and 
urgently needed and should be covered under the temporary state of emergency benefit. The Plan denied your 
request. The Plan says you are responsible for any charged amount above the Plans cost-sharing amount when 
your services are received from an out-of-network provider. Also, the denial of payment for the cone beam, 
extraction, excision of benign lesion, and deep sedation is correct because they are 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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The 
cone beam, extraction, excision of benign lesion, and deep sedation are not covered under the Plans dental 
benefit. Therefore, we decided that the Plan does not have to pay more for the limited oral evaluation (D0140), 
a cone beam (D0364), an extraction (D7210), excision of benign lesion (D7411), and deep sedation (D9222 
and D9223) for tooth #5 provided by out-of-network providers on August 31, 2022, and October 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intensity Modulated Radiation Therapy (IMRT) (77386, 
77470, G6002, J7030). 
 
You asked the Plan to pre-approve IMRT. You say that you have included a letter detailing why IMRT is the 
more appropriate treatment for the enrollee. The Plan denied your request. The Plan says the provider offers no 
documentation or evidence supporting the special need for IMRT in this lymphoma case. The request does not 
meet the Medicare or Plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of IMRT have been met. The records 
show the Plan made three attempts to request medical records from the provider and the records were not 
submitted. Therefore, we decided that the Plan does not have to pre-approve Intensity Modulated Radiation 
Therapy (IMRT) (77386, 77470, G6002, J7030).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an urgent care visit and a urine test provided on November 
20, 2022. 
 
You asked the Plan to pay for an urgent care visit and a urine test. You say that these services were medically 
necessary. 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 an urgent care visit and 
a urine test provided on November 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup, including any pins when required (D2950) 
provided on November 15, 2022. 
 
You asked the Plan to pay for core buildup. You say that this should be covered. The Plan denied your request. 
The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for core 
buildup, including any pins when required (D2950) provided on November 15, 2022.