Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the partial upper denture (D5213) provided on January 27, 2022. 
 
You asked the Plan to pay for the dental item. You say that you were advised when you signed up for the plan 
in 2021 there were no deductibles or copayments. You say that you were misinformed when you were told that 
nothing had changed in coverage of payments. You say that you were not advised there would be a 50% 
compensation from the plan for dental work performed. You also say that this bill is a hardship for you. The 
Plan denied your request. The Plan says the out of network cost share was applied 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 and partial upper denture is a covered 
service, the cost share amount applies. The record shows there is a 50% coinsurance for dental services received out of network. This is a contractual obligation you agreed to when you enrolled in the Plan's dental 
coverage. The record shows that the Plan paid 50% of the billed amount of $2,340, or $1,170. Therefore, we 
decided that the Plan does not have to pay for the partial upper denture (D5213) provided on January 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) for a wheelchair. 
 
You asked the Plan to pre-approve a power seat elevation system. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested item is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare 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. Based on 
this information, we decided that Medicare rules for coverage of a power seat elevation system have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300) 
for a wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on March 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that your crown broke off your tooth. You say that 
the dentist did not feel they could perform the extraction. You say that the new dentist required a pre-operative 
appointment. You also say that this is not unusual and should be covered. The Plan denied your request. The 
Plan says your benefit for the limited oral evaluation 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 Plan's 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 limited oral evaluation was exhausted on date of service March 9, 2022. Therefore, 
we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on March 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on October 13, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for genetic testing. 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 genetic testing provided on October 13, 2021, by 
an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A9279, S1015, and S8301 billed for date of 
service February 7, 2022. 
 
You asked the Plan to pay for procedure codes A9279, S1015, and S8301. You say that you would like the plan 
to reconsider their denial. 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 A9279, S1015, and S8301 has a Status Indicator of I on the Physician Fee 
Schedule. This means that procedure code A9279, S1015, and S8301 is not valid for Medicare purposes. Based 
on this information, we decided that Medicare rules for coverage of procedure codes A9279, S1015, and S8301 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes A9279, 
S1015, and S8301 billed for date of service February 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 27, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on December 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 10, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on January 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician visit services provided on February 22, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for physician visit services. You say that you would like to request reconsideration 
of the denied 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 physician visit services provided on February 22, 
2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology coded G0416 provided on September 
27, 2021.  
You asked the Plan to pay for the surgical pathology. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed exceed 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 G0416 is 1. The MAI value for this code is 2. You billed 6 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
surgical pathology have not been met. Therefore, we decided that the Plan does not have to pay for the surgical 
pathology coded G0416 provided on September 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 4, 2021, 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 August 4, 2021, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical pathology services provided on March 25, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for surgical pathology services. 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 surgical pathology services provided on March 25, 
2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion an interlaminar/interspinous process 
stablization/distraction device for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is a lack of evidence to support that interspinous spacer devices are as safe and 
effective as the gold standard of decompression. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that current evidence based medical guideline and peer reviewed literature do not fully support the spinal 
decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of large 
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical 
condition. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the request for Vertiflex Superion interspinous 
device at L4-5 is not medically reasonable or 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion an interlaminar/interspinous process stablization/distraction device for the 
enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis (SEWHO) provided 
on September 14, 2020. 
 
You asked the Plan to pay for the shoulder-elbow-wrist-hand orthosis. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the item rendered is not supported by the 
documentation. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Review of the file shows that there is no evidence of an enrollee-physician relationship with the 
prescribing physician. In addition, the claim history does not show that the enrollee had a diagnosis of right shoulder osteoarthritis. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the shoulder-
elbow-wrist-hand orthosis (SEWHO) provided on September 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee on 
February 17, 2022.  
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, this claim 
was billed with an invalid type of bill. This means this claim is not payable as billed. Therefore, we decided 
that the Plan does not have to pay for the home health services provided to the enrollee on February 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 83789 billed for date of service February 15, 
2022. 
 
You asked the Plan to pay for procedure code 83789. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says payment for code 83789 is bundled into payment for code 
G0481. 
 
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 83789 
is a column II code to column I code G0481. 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. 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 83789 billed for date of service February 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant at surgery services provided on September 10, 
2021. 
 
You asked the Plan to pay for the assistant at surgery services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the provider is not eligible to 
bill for assistant at surgery services per Medicare guidelines. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the assistant at surgery services 
provided on September 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 14, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on January 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an interlaminar/interspinous process 
stabilization/distraction device. 
 
You asked the Plan to pre-approve insertion of an interlaminar/interspinous process stabilization/distraction 
device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity 
has not been established. Therefore, coverage criteria have not been met. 
 
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 insertion of an interlaminar/interspinous 
process stabilization/distraction device. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found interlaminar distraction devices 
are 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 insertion of an interlaminar/interspinous process stabilization/distraction device 
have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an 
interlaminar/interspinous process stabilization/distraction device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for home INR equipment on January 4, 2022. 
 
You asked the Plan to waive the coinsurance for home INR equipment. You say that you would like to appeal 
the cost share. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for home INR equipment. The total coinsurance amount owed is $48.57. 
 
You have been asked to pay 20% coinsurance for home INR equipment. Home INR equipment 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 home INR equipment on January 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87640, 87641, 87653, and 
87798 billed for date of service June 9, 2021. 
 You asked the Plan to pay for procedure code 87150, 87481, 87640, 87641, 87653, and 87798. You say that 
you would like the plan to reconsider their denial. The Plan denied your request. The Plan says payment for 
codes 87150, 87481, 87640, 87641, 87653, and 87798 is bundled into payment for code 87150. 
 
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 87150, 
87481, 87640, 87641, 87653, and 87798 is a column II code to column I code 87150. 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 codes 87150, 87481, 
87640, 87641, 87653, and 87798 billed for date of service June 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for face mask interface replacements on 
November 15, 2021, to January 15, 2022. 
 
You asked the Plan to waive the copayment for face mask interface replacements. You say that you would like 
to appeal the cost share. The Plan denied your request. The Plan says the cost share 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 20% 
coinsurance for face mask interface replacements. The total allowed amount of the face mask interface 
replacements is $130.30, resulting in a coinsurance amount of $26.04. 
 
You have been asked to pay 20% coinsurance for face mask interface replacements. Face mask interface 
replacements fall 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 copayment for face mask interface replacements on November 15, 2021, to 
January 15, 2022.