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

 
We decided that the Plan does not have to pay for an office visit provided on April 7, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to appeal the denial of the claim. The 
Plan denied your request. The Plan says the provider is out-of-network and authorization is required prior to an 
out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on April 7, 2022, 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 the nuclear medicine study of heart muscle 
with a regadenoson injection. 
 
You asked the Plan to waive the copayment for the nuclear medicine study and injection. You say that you 
cannot use a treadmill or bicycle and these services were never rendered. 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 $75 
copayment for nuclear medicine and a 20% coinsurance for Part B medications and contrast agents.  
 
 Patients who are unable to exercise are given an injection agent like regadenoson for nuclear medicine studies. 
That is why you have been asked to pay $128.94 for a nuclear medicine copay and a Part B drug injections 
coinsurance ($75 for nuclear medicine study + $53.94 the allowed amount for injectable = $128.94). The 
nuclear medicine study falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 
benefit category. The injection falls with the Medicare Part B Prescription Drugs 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 the nuclear medicine study of heart muscle with a regadenoson 
injection.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic testing provided on March 24, 
2022. 
 
You asked the Plan to waive the copayment for diagnostic testing. You say that you weren't aware you would 
be charged $10 copayment for this service. The Plan denied your request. The Plan says the copayment applied 
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 $10 
copayment for outpatient diagnostic procedures and tests in a non-hospital setting.  
 
You have been asked to pay $10 copayment for diagnostic testing. Diagnostic testing 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 diagnostic testing provided on March 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical each additional radiographic image 
(D0230), 2D oral/facial photographic images (D0350 X 2), and a 3D photographic image (D0351) provided on 
April 29, 2022. 
 
You asked the Plan to pay for the x-rays. You say that you were not told that the x-rays would not be covered. 
The Plan denied your request. The Plan says theres no coverage for oral/facial photographic image x2 or 3D 
photographic images under your dental benefit plan. The Plan also says intraoral x-rays only allow one 
procedure per calendar year which is why the second intraoral x-ray is denied.  
 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 2D oral/facial photographic images 
(D0350 X 2), and 3D photographic image (D0351) are not among those covered under this benefit. 
Additionally, intraoral - periapical each additional radiographic image (D0230) is only covered one procedure 
per calendar year so the second intraoral x-ray is not covered. Therefore, we decided that the Plan does not 
have to pay for intraoral - periapical each additional radiographic image (D0230), 2D oral/facial photographic 
images (D0350 X 2), and a 3D photographic image (D0351) provided on April 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical procedures on arteries and veins, endovascular 
revascularization. 
 
You asked the Plan to pre-approve surgical procedures on arteries and veins, endovascular revascularization. 
You say that surgical procedures on arteries and veins, endovascular revascularization is medically necessary. 
The Plan denied your request. The Plan says surgical procedures on arteries and veins, endovascular 
revascularization does not meet the Medicare NCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 surgical procedures on arteries and 
veins, endovascular revascularization. Our reviewer says that surgical procedures on arteries and veins, 
endovascular revascularization is not medically necessary. Our physician reviewer found the documentation 
does not support the medical necessity of the treatments in question. The enrollees most recent office note 
documents that the enrollee is having no pain in his legs and no complaints other than constipation. There is no 
documentation of any ulceration or tissue loss of the lower extremities. It is documented that the enrollee is 
having shortness of breath with exertion. There is documentation that ABIs have been ordered but the results 
are not provided. The codes in question code for treatment in the femoropopliteal arteries for which there is no 
documentation of occlusive disease. It is not possible to overturn the health Plans determination in the absence 
of a documented indication for treatment.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of surgical procedures on arteries and veins, endovascular revascularization have 
not been met. Therefore, we decided that the Plan does not have to pre-approve surgical procedures on arteries 
and veins, endovascular revascularization.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 2, 2021, to 
October 1, 2021. 
 
You asked the Plan to pay for home health services. You say that the medically necessary services at issue 
were provided to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment for 
home health services have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that HHAs must submit a RAP within five calendar 
days after the start of care.  
 
We looked at the file and Medicare rules. In this case, there is no evidence that a RAP was submitted within 
five calendar days after the start of care. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pay 
for home health services provided from September 2, 2021, to October 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SmartPill. 
 
You asked the Plan to pre-approve the SmartPill. You say that SmartPill is medically necessary. The Plan 
denied your request. The Plan says the requested SmartPill does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 SmartPill. Our reviewer says that 
SmartPill is not medically necessary. Our physician reviewer found per the available records; the enrollee does 
not have objectively demonstrated significant gastroparesis but is reported to have dysphagia. The enrollees 
available record therefore does not meet provided criteria for the SmartPill study under review.  
 
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 SmartPill have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SmartPill.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220), 
intraoral - periapical each additional radiographic image (D0230), and limited oral evaluation - problem 
focused (D0140) provided December 14, 2021. 
 
You asked the Plan to pay for the periapical x-rays and limited oral exam. You say that these dental services 
were necessary due to an accident. The Plan denied your request. The Plan says your dental benefit has been 
exhausted. Additionally, the Plan says these services are not covered under your medical 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 x-rays and 
exams up to $1,000 every year. 
The services you are asking the Plan to pay for 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. The Plan provided documentation showing that your full $1,000 dental benefit was exhausted 
prior to the requested dental claim. Therefore, we decided that the Plan does not have to pay for the intraoral - 
periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), 
and limited oral evaluation - problem focused (D0140) provided December 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two-dimensional (2D) oral/facial photographic images 
(D0350), oral hygiene instructions (D1330), gingival irrigations (D4921), and local anesthesia in conjunction 
with operative or surgical procedures (D9215) provided on January 12, 2022. 
 
  You asked the Plan to pay for the 2D oral/facial photographic images, oral hygiene instructions, gingival 
irrigations, and local anesthesia. You say that the dentist did not do a pre-authorization for the enrollee's 
cleaning. You also believe the enrollee should not be held responsible because it is the dental group's fault. The 
Plan denied your request. The Plan says these services are not covered expenses under the enrollee's dental 
plan. The Plan also says that the Plan was not contacted prior to the date of service to verify benefits and 
provider eligibility. 
 
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 two-
dimensional (2D) oral/facial photographic images (D0350), oral hygiene instructions (D1330), gingival 
irrigations (D4921), and local anesthesia in conjunction with operative or surgical procedures (D9215) 
provided on January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive periodontal evaluation on May 18, 2022. 
 
You asked the Plan to pay for comprehensive periodontal evaluation. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the service is not a covered 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 
comprehensive periodontal evaluation on May 18, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213), skin graft (15271), and 
Floweramniopatch (Q4178) provided on June 2, 2021. 
 
You asked the Plan to pay for the physician services. You say that the enrollee's treatment was not related to 
their hospice diagnosis. The Plan denied your request. The Plan says the enrollees claim would be covered 
under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until 
the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to 
verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
  
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 the office visit (99213), skin graft (15271), and 
Floweramniopatch (Q4178) provided on June 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oncology gene expression profiling (81529) billed for date of 
service March 28, 2022. 
 You asked the Plan to pay for lab services. You say that these services were medically necessary and were 
billed appropriately. The Plan denied your request. The Plan says this claim was billed with an incorrect date of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that unless a specific exception is met, then the date 
of service for either a clinical laboratory test or the technical component of physician pathology service should 
be billed as the date that the sample was taken. 
 
We looked at the file and Medicare rules. The collection facility for the sample in this case was not a hospital 
facility, and therefore none of the exceptions to the general rule apply. Although this claim was billed with a 
date of service of March 28, 2022, the record shows that the specimen was collected on March 7, 2022. This 
means that the correct date of service for this claim would be March 7, 2022. Based on this information, we 
decided that Medicare rules for billing lab services have not been met. Therefore, we decided that the Plan does 
not have to pay for oncology gene expression profiling (81529) billed for date of service March 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81479, 81286, 81414, 81442, and 81400 
billed for date of service August 23, 2021. 
 
You asked the Plan to pay for procedure code 81479, 81286, 81414, 81442, and 81400. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says payment for codes 81479, 81286, 
81414, 81442, and 81400 are bundled into payment for code 81413. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Code 81479 is not supported by the 
documentation. In addition, we have confirmed that codes 81286, 81414, 81442, and 81400 are column II 
codes to column I code 81413. 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 81479, 81286, 81414, 81442, and 81400 billed for date of service 
August 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical x-rays (D0230), cone beam computed 
tomography (CT) (D0364), root canal (D3330), and core build up (D2950) provided from March 16, 2022, to 
March 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied 
your request. The Plan says the services are 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, there are certain coverage limitations 
that apply. The record shows that the plan paid for one dental x-ray that you received on the date of service in 
this case, thus exceeding the benefit of one every 6 months. Additionally, the cone beam CT, root canal, and 
core build up are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periapical x-rays (D0230), cone beam computed tomography (CT) (D0364), root canal (D3330), 
and core build up (D2950) provided from March 16, 2022, to March 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from February 15, 2022, 
to February 17, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that HH PPS claims must report a 0023 revenue code line 
on which the first four positions of the HIPPS code match the code submitted on the RAP. 
 
We looked at the file and Medicare rules. The file shows that the claims were not billed with the required 0023 
revenue code. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the home health services rendered 
from February 15, 2022, to February 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluorouracil injection rendered on February 24, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that services with status indicator N are paid under the 
OPPS, but their payment is packaged into payment for a separately paid service. 
 
We looked at the file and Medicare rules. Billed procedure code J9190 has an OPPS status indicator of N and 
no separate payment. Therefore, we decided that the Plan does not have to pay for the fluorouracil injection 
rendered on February 24, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for subsequent nursing facility care (99309) provided from January 13, 
2022, to January 17, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says that rules for payment have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The CPT Code Manual definition of code 99309 is "Subsequent nursing facility care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient has 
developed a significant complication or a significant new problem. Typically, 25 minutes are spent at the 
bedside and on the patient's facility floor or unit." 
 
In this case, the Plan has denied stating that CPT code 99309 indicates nursing facility care that should be 
billed with Place of Service (POS) code 32. The services at issue have been billed with POS code 31, indicating 
a skilled nursing facility. However, the Plan has not indicated a rule nor is there anything in the code definition 
to exclude skilled nursing care. 
 
It is the Plan's responsibility to substantiate its denial with evidence. In this case, the denial has not been 
substantiated, so we must find in your favor. Therefore, we decided that the Plan has to pay for subsequent 
nursing facility care (99309) provided from January 13, 2022, to January 17, 2022.  
 
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.