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

 
We decided that the Plan does not have to pay for 15 units of ambulance mileage (A0425) provided on 
November 30, 2021. 
 
You asked the Plan to pay for ambulance mileage. You say that these services were necessary and are 
supported in the record. The Plan denied your request. The Plan says ambulance mileage has an MAI of 1 with 
an MUE of 250. This means that only 250 units of ambulance mileage may be billed on a single line, and 
additional units must be reported on a separate line. The submitted claim reports 265 units on one line; 
therefore, the Plan has approved 250, and the additional 15 which exceed the MUE for this service units are 
denied. The Plan must follow Medicare rules. Medicare rules say that if a code has an MAI of 1, appropriate use of a 
modifier may be used to report the same code on separate lines of the claim. Each line of the claim with that 
HCPCS/CPT code will be separately adjudicated against the MUE value for that HCPCS/CPT code. 
 
In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 1. You billed 265 units of 
this code on a single claim line, exceeding the MUE. Based on this information, we decided that Medicare rules 
for coverage of ambulance mileage have not been met. Therefore, we decided that the Plan does not have to 
pay for 15 units of ambulance mileage (A0425) provided on November 30, 2021.
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 March 18, 2021. 
 
You asked the Plan to pay for procedure code 99100. You say that you have submitted records to support 
payment. The Plan denied your request. The Plan says separate payment is not made for this code. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
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 March 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy (PT) services provided 
from November 30, 2021, to December 30, 2021. 
 
You asked the Plan to waive the copayments for the PT services. You say that you feel you are being charged 
twice for the same dates. 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 $20 
copayment for each physical therapy visit at a specialist's office or comprehensive outpatient rehab facility.  
 
The file shows you had a total of 9 PT visits from November 30, 2021, to December 30, 2021. Therefore, you 
have been asked to pay a $20 copayment for each visit for the PT services. The total for all visits is $180 ($20 
copayment x 9 visits = $180). The PT services fall within the Outpatient Rehabilitation 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 copayments for physical therapy (PT) services provided from 
November 30, 2021, to December 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve consultation services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve consultation services. You say that you are requesting an out of plan referral 
for a consultation and another opinion regarding your lymphedema. The Plan denied your request. The Plan 
says they will not refer the member to a non-Plan Cardiologist for a second opinion consultation because the 
services are available in Plan and the member is contractually required to obtain this service from network 
providers. 
 
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 
consultation services to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a magnetic resonance imaging (MRI) of 
the cervical spinal canal provided on January 10, 2022. 
 
You asked the Plan to reduce the copayment for an MRI. You say that you are unhappy with your share of the 
cost. 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 $145 
copayment for in-network radiological diagnostic services, including MRIs.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$145 copayment for an MRI. An MRI 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 reduce the copayment for a magnetic resonance 
imaging (MRI) of the cervical spinal canal provided on January 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medicine applied to gum space around a tooth (per tooth) for 
management of gum disease (D4381) provided on December 22, 2021. 
 
You asked the Plan to pay for medicine for management of gum disease. You say that you did not know you 
could not have these services on the same days and trusted that your dentist would provide appropriate care. 
The Plan denied your request. The Plan says this service is not covered on the same day as scaling and root 
planing. 
 
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 medicine for 
management of gum disease, but this service is not covered on the same date as scaling or root planing services 
(D4341 or D4342). 
 
We looked at the file and Medicare rules. The record shows that on the date in question you also received 
periodontal scaling and root planing services (D4342). Based on this information, we decided that the Plan's 
rules for coverage of medicine for management of gum disease have not been met. Therefore, we decided that 
the Plan does not have to pay for medicine applied to gum space around a tooth (per tooth) for management of 
gum disease (D4381) provided on December 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (ECG) provided on 
February 8, 2022. 
 
You asked the Plan to waive the copayment for an ECG. You say that this should be covered as the ECG was 
part of your wellness visit. 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 $10 
copayment for outpatient diagnostic tests, including ECGs. The contract also says you will only pay one 
copayment per day even if multiple tests are performed. 
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$10 copayment for an ECG. An ECG 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 an electrocardiogram 
(ECG) provided on February 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit and ECG provided on 
January 28, 2022. 
 
You asked the Plan to waive the copayment for an office visit and ECG. You say that you never had to pay for 
this before so it should be covered. 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 $25 
copayment for Medicare-covered radiological diagnostic services, not including x- rays and $20 copayment for 
services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or 
physicians assistant or other non-physician. 
 You have been asked to pay $35.61 copayment for the office visit and ECG ($20 + $15.61 = $35.61).The ECG 
falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category and the 
office visit falls within the Physician/Practitioner Services, Including Doctors Office Visits 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 office visit and ECG provided on January 28, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the CxBladder testing provided on August 20, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that a decision was not 
rendered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan issued payment twice for this testing, and recouped payment both 
times. After recoupment, the Plan did not provide a denial rationale for the testing. Without a reason for denial, 
the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the CxBladder 
testing provided on August 20, 2020.  
 
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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient electroencephalogram (EEG) provided to the 
enrollee on September 3, 2021. 
 
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 services were approved as outpatient. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for an outpatient electroencephalogram (EEG) provided to the enrollee on September 
3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection, lidocaine HCl for intravenous infusion, 10 mg 
(J2001) provided June 30, 2021. 
 
You asked the Plan to pay for the injection. You say that please see attached medical records showcasing the 
medical necessity of the services provided. The Plan denied your request. The Plan says the records do not 
support service 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 code J2001 is injection, lidocaine HCl for intravenous 
infusion, 10 mg.   
We find that CPT code J2001 is not supported in the medical record. Specifically, the documentation indicates 
that a lidocaine infiltration/injection through a non-intravenous route was performed. There is a more 
appropriate HCPCS code that should be used to bill for an unclassified drug. In addition, J3490 has been 
processed on this claim. Based on this information, we decided that Medicare rules for coverage of the 
injection have not been met. Therefore, we decided that the Plan does not have to pay for injection, lidocaine 
HCl for intravenous infusion, 10 mg (J2001) provided June 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
November 30, 2021, to January 18, 2022. 
 
You asked the Plan to pay for dental services. You say that it was more cost effective to see an out-of-network 
provider. The Plan denied your request. The Plan says services provided by an out-of-network provider are not 
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. The Plan covers covered 
dental services when the services are provided by an out-of-network provider. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for 
dental services provided by an out-of-network provider on November 30, 2021, to January 18, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy visits from October 27, 
2021, to December 8, 2021. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you should not have to pay the 
bills for physical therapy because you were having no progress in your treatment. The Plan denied your 
request. The Plan says coinsurance 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 $40 
copayment for each Medicare-covered physical therapy and speech-language therapy visit.  
 
  You have been asked to pay a total of $240 for physical therapy visits ($40/visit x 6 visits = $240). Physical 
therapy falls within the Outpatient Rehabilitation 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 physical therapy visits from October 27, 2021, to December 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
January 11, 2022. 
 
You asked the Plan to pay for dental services. You say that you were never told this provider was not in-
network. The Plan denied your request. The Plan says services provided by an out-of-network provider are not 
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. The Plan covers covered 
dental services when they are provided by a participating provider. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for 
dental services provided by an out-of-network provider on January 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shower/bath chair you purchased on October 31, 2021. 
 
You asked the Plan to pay for a shower/bath chair. You say that this item would not fit in your tub, so you 
could not use it.  You said that you tried to return it but the provider wouldn't accept it back. The Plan denied 
your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pay for a shower/bath chair you purchased on 
October 31, 2021.  
 
Your complaint about the provider not taking this item back is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints. In addition, on this same date, it appears you were also charged 
coinsurance for a commode chair.  Your appeal request did not address this coinsurance, so we are not 
addressing it here.  If you wish to appeal the coinsurance for the commode chair, please contact the Plan 
directly.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hot or cold packs therapy (97010) provided on January 28, 2022. 
 
You asked the Plan to pay for hot or cold packs therapy. You say that therapy services were pre-approved by 
the Plan and should be paid. The Plan denied your request. The Plan says they have agreed to pay for the 
therapy services; however, payment for hot or cold packs therapy, billed with code 97010, is always bundled 
into the payment for another service 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 CPT code. 
 We find that CPT code 97010 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 97010 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of hot or cold packs therapy have not been met. Therefore, we decided that the Plan does not have to pay for 
hot or cold packs therapy (97010) provided on January 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ECG provided on November 11, 2021. 
 
You asked the Plan to waive the copayment for ECG. You say that this charge should be covered. 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 $30 
copayment for Medicare-covered non radiological diagnostic services.  
 
You have been asked to pay $11.13 which is less than the standard $30 copayment for ECG. ECG 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 ECG provided on November 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of residual tooth roots (cutting procedure) 
(D7250) and implant removal, by report (D6100) provided December 6, 2021. 
 
You asked the Plan to pay for the removal of residual tooth roots and implant removal. You say that you went 
to the dentist because you were in pain. You cannot afford the cost of these services. The Plan denied your 
request. The Plan says these services are not covered under your benefits. 
 
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, 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 removal of residual tooth roots (cutting 
procedure) (D7250) and implant removal, by report (D6100) provided December 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete denture - maxillary (D5110) and complete 
denture - mandibular (D5120) provided December 9, 2021. 
 
You asked the Plan to pay for the complete upper and lower dentures. You say that you were told your dentures 
would be covered. The Plan denied your request. The Plan says the complete dentures are not covered under 
your 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 the 
complete denture - maxillary (D5110) and complete denture - mandibular (D5120) provided December 9, 
2021.  
 Your complaint about potentially being provided misinformation is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.