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

 We decided that the Plan does not have to pay for surgical services (procedure code 43235 and 49905) 
provided to the enrollee on July 27, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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, the CPT Code Manual definition of the denied codes is: 
 
CPT 43235: 
 
Esophagogastroduodenoscopy (EGD), flexible, transoral; diagnostic, including collection of specimen(s) by 
brushing or washing, when performed (separate procedure) 
 
 
 CPT 49905: 
 
Omental flap, intra-abdominal (List separately in addition to code for primary procedure) 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 43235, use of EG 
is a choice to perform a leak test during a sleeve gastrectomy, as there are a multitude of manners to perform 
(using ICG, methylene blue or air) with or without an EGD and using an oral gastric tube as example. This is a 
component of the sleeve gastrectomy and does not constitute a separate procedure. In terms of CPT 49905, the 
decision to sew omentum to the staple line is not a standard component of sleeve gastrectomy without literature 
to prove that is an effective, durable treatment. The decision to sew omentum to the staple line as reinforcement 
is a provider choice, but does not constitute an omental flap that can be considered a separate billable 
component of the sleeve gastrectomy, but part of the sleeve gastrectomy itself based on the provider's 
technique. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services (procedure code 43235 and 49905) provided to the enrollee on July 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on July 29, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you didnt think it would cost 
this much or you wouldnt have had the surgery. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for Outpatient surgery in a hospital outpatient facility. 
 
You have been asked to pay a $325 copayment for outpatient surgery. This item/service falls within the 
Outpatient surgery in a hospital outpatient facility benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for outpatient surgery provided on July 29, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound provided on September 11, 
2021. 
 
You asked the Plan to waive the copayment for ultrasound. You say that this should be covered. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for Medicare covered x-rays. 
 
You have been asked to pay a $50 copayment for ultrasound. This item/service falls within the Medicare 
covered x-rays 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 ultrasound provided on 
September 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs (A9270) provided on September 21, 
2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not a covered benefit. 
 
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 provided are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs (A9270) 
provided on September 21, 2022.  
 Benefits for these items 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87150- 59, 87798-59, 
87640-59 and 87641-59) provided on December 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 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. 
 
Current Procedural Terminology (CPT) code 87150-59 (12 Units) remains not supported. This code is included 
in Current Procedural Terminology (CPT) 87500; therefore, it cannot be separately reimbursed. The documents 
received do not support that the procedure or service was distinct or independent from other services 
performed; therefore, the use of the 59 modifier is not supported. 
 
Current Procedural Terminology (CPT) code 87798-59 (2 Units) remains not supported. This code is included 
in Current Procedural Terminology (CPT) 87150 and 87801; therefore, it cannot be separately reimbursed. The 
documents received do not support that the procedure or service was distinct or independent from other 
services performed; therefore, the use of the 59 modifier is not supported. 
 
Current Procedural Terminology (CPT) code 87640-59 (1 Unit) remains not supported. This code is included in 
Current Procedural Terminology (CPT) 87150, 87641 and 87801; therefore, it cannot be separately reimbursed. 
The documents received do not support that the procedure or service was distinct or independent from other 
services performed; therefore, the use of the 59 modifier is not supported. 
 
Current Procedural Terminology (CPT) code 87641-59 (1 Unit) remains not supported. This code is included in 
Current Procedural Terminology (CPT) 87150 and 87801; therefore, it cannot be separately reimbursed. The 
documents received do not support that the procedure or service was distinct or independent from other 
services performed; therefore, the use of the 59 modifier is not supported. 
 
on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87150- 59, 
87798-59, 87640-59 and 87641-59) provided on December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth (D7210) provided on August 3, 2022. 
 
You asked the Plan to pay more for the dental services. 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. 
 
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. 
Therefore, we decided that the Plan does not have to pay more for an extraction, erupted tooth requiring 
removal of bone and/or sectioning of tooth (D7210) provided on August 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the root canal (D3320), the post and core filling (D2952), 
and the metal and white crown (D27451) provided from May 31, 2022, to June 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believe the services were medically 
necessary. 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 the root canal (D3320), the post and core filling (D2952), and the metal and white crown (D27451) 
provided from May 31, 2022, to June 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 19, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
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).there was no preauthorization by a primary care provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on January 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) provided by an out-of-network provider 
on August 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 6, 2022. Therefore, 
we decided that the Plan does not have to pay for prophylaxis (D1110) provided by an out-of-network provider 
on August 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on June 02, 2022. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that the 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 the domiciliary or rest 
home visit provided on June 02, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CT scan provided on November 6, 2021. 
 
You asked the Plan to pay for the CT scan. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and 
was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
 
  We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on 11/17/2021. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for the CT scan have not been met. Therefore, we 
decided that the Plan does not have to pay for a CT scan provided on November 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum assisted socket system (VASS). 
 
You asked the Plan to pre-approve VASS. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are covered when specific 
criteria are met. 
 
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 VASS. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, the enrollee has had a recent 
replacement socket. The requested device has not been shown to be superior to other standard treatments for 
the medical condition. The requested VASS for the prosthesis is not medically necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of VASS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a vacuum assisted socket system (VASS).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dentures (D5110, D5120) 
 
You asked the Plan to pre-approve 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 plan benefits. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
 
  The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve dentures (D5110, 
D5120)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 21, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
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).there was no preauthorization by a primary care provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on June 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a panoramic radiographic image (D0701) 
 
You asked the Plan to pre-approve 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 pre-approve a 
panoramic radiographic image (D0701)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the medical eye exam provided on June 10, 
2022. 
 
You asked the Plan to waive the copayment for the medical eye exam. You say that routine eye exams have a 
$0 copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for per visit for Medicare-covered exams to diagnose and treat diseases of the eye.  
 
You have been asked to pay a $30 copayment for the medical eye exam. This item/service falls within vision 
care benefit category. The medical record shows diagnoses for type two diabetes without macular edema, 
vitreous degeneration, and cataracts which makes the eye exam medical in nature. Please note, there was no 
charge for the refraction. 
 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 the medical eye exam provided on June 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care services provided on March 10, 2022, to 
March 31, 2022. 
 
You asked the Plan to pay for the wound care services. You say that the 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 the wound care services 
provided on March 10, 2022, to March 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical dental services (D6010) provided on July 28, 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 surgical 
dental services (D6010) provided on July 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-rays provided on August 17, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for x-rays. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says generally, the enrollee must obtain their treatment from network providers. However, 
some exceptions apply, such as if they require emergency services or urgently needed services when the 
network is not available (generally, when the enrollee is out of the service area), and out-of-area dialysis 
services. In these circumstances, prior authorization to seek out-of-network treatment is not required. 
 
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 x-rays provided on August 17, 2022, by an out-of-
network (OON) provider.