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

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service August 4, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says procedure code 99100 is considered 
bundled and not separately payable. 
 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service August 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite (D2332) provided on September 14, 
2021. 
 
You asked the Plan to pay for the dental services. You say that the requested services are needed. 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 resin-based composite (D2332) provided on September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulation (G0283) provided from July 18, 
2022, through July 27, 2022. 
 
You asked the Plan to pay 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 these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the electrical stimulation (G0283) provided from July 18, 2022, through 
July 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

Expandable 
We decided that the Plan does not have to pre-approve the seat elevator (E2300) controller (E2377) expandable 
controller harness (E2313) and electronic connection (E2311). 
 
You asked the Plan to pre-approve the seat elevator and upgraded electronics. You say that please review the 
attached medical documentation to support the need of the custom medical equipment being requested. The 
Plan denied your request. The Plan says the upgraded electronics are not medically necessary as the approved 
power options come with their own switches and the seat elevator is does not serve a primary medical purpose 
 
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 seat elevator and upgraded 
electronics. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the provided records document that the enrollee has wrist 
extension and flexion within functional limits with no reported limitations in upper extremity-related activities 
of daily living, thus indicating she has adequate upper extremity strength and function to operate the 
wheelchairs power options with their own switches. The requested power seat elevation feature is statutorily 
non-covered as it serves no primary medical purpose. 
 
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 seat elevator and upgraded electronics have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the seat elevator (E2300) controller (E2377) expandable 
controller harness (E2313) and electronic connection (E2311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periapical radiographic imaging (D0220 and D0230) 
provided by an out-of-network provider on August 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believe these charges should be paid. 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 August 9, 2022. Therefore, we decided that the Plan does not have to pay for periapical radiographic imaging (D0220 and 
D0230) provided by an out-of-network provider on August 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral hygiene instructions (D1330) and periodontal 
maintenance (D4910) provided on August 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told the dentist was an in-network 
provider. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because the oral hygiene instructions and periodontal maintenance 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. 
 
  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 oral 
hygiene instructions (D1330) and periodontal maintenance (D4910) provided on August 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a routine ophthalmological examination 
including refraction (S0621) provided on August 14, 2022. 
 
You asked the Plan to waive the copayment for a routine ophthalmological examination including refraction 
(S0621). You say that you plan covers one eye exam refraction whether in- or out-of-network per year. 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 $25 
copayment for a specialist's office visit for Medicare covered vision services.  
 
You have been asked to pay a $25 copayment for a routine ophthalmological examination including refraction 
(S0621). This item/service falls within the specialist's office visit for Medicare covered vision services benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for a routine ophthalmological examination 
including refraction (S0621) provided on August 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercises (97110) and the therapeutic 
activities (97530) provided on August 8, 2022. 
 
You asked the Plan to pay 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 these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
 The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the therapeutic exercises (97110) and the therapeutic activities (97530) 
provided on August 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 20, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not payable as billed. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
Review of the file does not support how the enrollee came to the servicing provider, or whether the services 
rendered were medically necessary. This means that the laboratory testing at issue in this appeal was requested 
solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on April 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye examination and an eye refraction 
provided on June 21, 2022. 
 
You asked the Plan to waive the copayment for an eye examination and an eye refraction. You say that you are 
appealing with supporting records. 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 an examination to diagnose and treat diseases and conditions of the eye.  
 
 You have been asked to pay a $30 copayment for an eye examination and an eye refraction. This item/service 
falls within the exam to diagnose and treat diseases and conditions of the eye benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for an eye examination and an eye refraction provided on June 21, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97140, 97010 and 97026 billed for date of 
service March 1, 2022. 
 
You asked the Plan to pay for procedure codes 97140, 97010 and 97026. You say that these services were 
necessary and are supported in the medical records. The Plan denied your request. The Plan says payment for 
code 97140 is bundled into payment for code 97012. Procedure code 97010 is considered bundled and not 
separately payable. In addition, procedure code 97026 is for infrared therapy services which are not covered by 
Medicare or the Plan. 
 
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 rules also say that the use of infrared and/or 
near-infrared light and/or heat, including monochromatic infrared energy, is non-covered. 
 
In this case, we have confirmed that code 97140 is a column II code to column I code 97012. This claim has 
not been billed with an appropriate modifier to bypass the edit. In addition, we find that procedure code 97010 
has a status indicator of B on the Physician Fee Schedule. This means procedure code 97010 is not separately 
payable. Based on the claim submitted, Medicare billing criteria have not been met. In addition, we find that 
code 97026 reports infrared therapy which is not a covered service. Therefore, we decided that the Plan does 
not have to pay for procedure codes 97140, 97010 and 97026 billed for date of service March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) provided on May 19, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99203) provided on May 19, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropathy treatment to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON neuropathy treatment. You say that this is the only place that has 
helped you, but you were not aware it was not in network. The Plan denied your request. The Plan says they 
do not cover non-emergency services by a non-contracted provider when a contracted provider can do the 
services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
neuropathy treatment to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rhythm electrocardiogram (ECG) provided on May 17, 
2022. 
 
You asked the Plan to pay for the rhythm ECG. You say that this should be paid because the enrollee walked in 
with symptoms requiring immediate care. The Plan denied your request. The Plan says all services were paid 
except for the ECG as there is no evidence this was performed nor that it was medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that rhythm ECGs are used to evaluate signs and 
symptoms that may reflect a cardiac rhythm disorder.  
 
We looked at the file and Medicare rules. The progress note shows that the enrollee's only symptom was knee 
pain. There was no documentation of suspicion for a cardiac rhythm disorder. The note also does not clearly 
document that an ECG was performed. Based on this information, we decided that Medicare rules for coverage 
of the rhythm ECG have not been met. Therefore, we decided that the Plan does not have to pay for the rhythm 
electrocardiogram (ECG) provided on May 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 an Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Intracept procedure is experimental. More research is needed to demonstrate 
its safety and effectiveness. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628, 64629).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, the enrollee can receive the care they need in another setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a subcutaneous cardiac rhythm monitor. 
 
You asked the Plan to pre-approve insertion of a subcutaneous cardiac rhythm monitor. You say that the 
clinical information provided supports the need for the requested services. The Plan denied your request. The 
Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We 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 a subcutaneous cardiac 
rhythm monitor. Our reviewer says that insertion of a subcutaneous cardiac rhythm monitor is not considered 
medically reasonable and necessary in this case. Our physician reviewer found while the enrollee has a history 
of atrial fibrillation, there is no documentation provided to suggest a history of unexplained syncope or any 
other apparent indication for an implantable loop recorder. There is insufficient documentation to support the 
medical necessity for insertion of an implantable loop recorder in the enrollees clinical management. 
 
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 a subcutaneous cardiac rhythm monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of a subcutaneous cardiac rhythm 
monitor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine culture (87086) provided on June 23, 2022. 
 
You asked the Plan to pay for the urine culture. You say that this service was medically necessary and 
reasonable. The Plan denied your request. The Plan says the diagnosis billed on this claim does not support the 
medical necessity of this urine culture. 
 
The Plan must follow Medicare rules. Medicare rules say that there are certain diagnosis codes which support 
the medical necessity of code 87086. Codes which are not included in the coding manual list are considered not 
medically necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the urine culture have not been met. Specifically, the diagnosis code(s) billed on this claim are not 
included on the list of appropriate codes to support the medical necessity of procedure code 87086. Therefore, 
we decided that the Plan does not have to pay for the urine culture (87086) provided on June 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction service (92015) provided on August 5, 2022. 
 You asked the Plan to pay for the refraction service. You say that you have to see an Ophthalmologist due to 
your eye condition. The Plan denied your request. The Plan says refraction services are not covered when 
performed by an Ophthalmologist. 
 
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 a refraction is performed as part of a routine vision eye exam by 
an Optometrist. 
 
We looked at the file and the Plan's rules. The Plan covers a refraction is performed as part of a routine vision 
eye exam by an Optometrist. Based on this information, we decided that the Plan's rules for coverage of the 
refraction service have not been met. Additionally, the record shows that you signed an office policy form 
acknowledging that refractions are not covered by Medicare and a $30 fee will apply. Therefore, we decided 
that the Plan does not have to pay for the refraction service (92015) provided on August 5, 2022.