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

 
We decided that the Plan has to pay for the hearing aids (V5261) provided March 19, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that the hearing aids should be paid. The Plan denied 
your request. The Plan says that the billed services were not supported. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan pays for 
hearing aids up to a $2,000 hearing aid benefit every 3 years. 
 
We looked at the file and the Plan's rules. In this case the documentation showing the enrollee received hearing 
aids and a reimbursement request was submitted. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have been met. Therefore, we decided that the Plan has to pay for the hearing aids 
(V5261) provided March 19, 2021.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received from December 10, 2021, 
to December 12, 2021. 
 
You asked the Plan to pay for the drugs. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services on this claim are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs received 
from December 10, 2021, to December 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from March 30, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from March 30, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from March 
30, 2022, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental 
health treatment beyond the date in question of March 30, 2022, forward. Our physician reviewer found the 
enrollee did not require inpatient mental health treatment beyond March 30, 2022, as he was not a danger to 
himself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active 
treatment was taking place beyond the date in question. It did not appear that the services for the dates in 
question were reasonably expected or medically necessary to improve the enrollee's condition or for the 
purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from March 30, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from March 30, 
2022, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical procedure for isolation of tooth with rubber 
dam (D3910) and canal preparation and fitting of preformed dowel or post (D3950). 
 
You asked the Plan to pre-approve the surgical procedure for isolation of tooth with rubber dam and canal 
preparation and fitting of preformed dowel or post. The Plan denied your request. The Plan says these services 
are not covered under your benefit 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 pre-approve a 
surgical procedure for isolation of tooth with rubber dam (D3910) and canal preparation and fitting of 
preformed dowel or post (D3950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) provided on November 15, 2021. 
 
You asked the Plan to pay for the crown. You say that you have a dental rider for the 2021 plan year and have a 
total allowance of $1,500 per year. You also say that you qualify for a 50% reimbursement for the crown work 
that was done. The Plan denied your request. The Plan says this service is not a covered benefit under your 
dental 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. The record shows that this service was rendered prior to the activation 
of the dental rider on December 1, 2021. Therefore, we decided that the Plan does not have to pay for the 
crown (D2740) provided on November 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 8, 
2021. 
 
You asked the Plan to pay for procedure code 70450. You say that this patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for 70450 is bundled into payment for 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service December 8, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99213) provided on October 13, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that your services were rendered in the hospital setting 
and in good faith that the hospital complied with all authorization requirements. The Plan denied your request. 
The Plan says enrollees must receive their medical services from an in-network provider with the exception 
being urgent or emergent services. Non-emergent services with non-contracted providers require prior 
authorization before services being rendered. 
 
 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 the outpatient office visit (99213) provided on 
October 13, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional Physical Therapy (PT) visits. 
 
You asked the Plan to pre-approve 6 additional PT visits. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the requested services are not medically necessary. 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 6 additional PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the records do not demonstrate that the unique skills of a 
professional therapist are required to safely and effectively provide treatment, that the services can be safely 
and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a 
therapist. You should be able to transition to an independent home program at this point. The requested 
services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a 
qualified therapist is not required to establish, design and/or deliver a program to maintain your current 
condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 6 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 6 additional Physical Therapy (PT) visits.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medical services coded 63048 and 22853 provided on 
June 23, 2021. 
 
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says these services are included in payment to 
other services. 
 
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 63048 is laminectomy, facetectomy and foraminotomy 
(unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or 
lateral recess stenosis]), single vertebral segment; each additional vertebral segment, cervical, thoracic, or 
lumbar (List separately in addition to code for primary procedure) 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the medical services. Our reviewer says that the 
documentation does not support payment for the services as billed. Our reviewer found the that the procedure 
report documents L4-L5 and L5-S1 were the only interspaces procedures performed.  Per the CMS CCI 
Manual, under chapter 4 CPT codes 20000-29999 "CMS payment policy does not allow separate payment for 
CPT codes 63042 (laminotomy...; lumbar) or 63047 (laminectomy...; lumbar) with CPT codes 22630 or 22633 
(arthrodesis; lumbar) when performed at the same interspace. If the two procedures are performed at different 
interspaces, the two codes of an edit pair may be reported with modifier 59 appended to CPT code 63042 or 
63047."  In this case, modifier -59 cannot be verified. 
 
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 22853 
is a column II code to column I code 22849. 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. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan 
does not have to pay for the medical services coded 63048 and 22853 provided on June 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram (93010) and services provided 
between 10:00 PM and 8:00 AM (99053) provided on February 4, 2021. 
 
You asked the Plan to pay for the medical services. You say that you would like these codes reprocessed and 
approved for payment. The Plan denied your request. The Plan says no separate payment can be made for these 
services according to Medicare rules. 
 
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 93010 
is a column II code to column I code 29105. 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.  
 
In addition, code 99053 has a Status Indicator of B under the Physician Fee Schedule. This means that 
Payment for covered services are always bundled into payment for other services not specified and no separate 
payment is due. 
 
Therefore, we decided that the Plan does not have to pay for the electrocardiogram (93010) and services 
provided between 10:00 PM and 8:00 AM (99053) provided on February 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950) on tooth #31. 
 
You asked the Plan to pre-approve core buildup. You say that you are in pain and may have an infection due to 
having to wait to replace the tooth. The Plan denied your request. The Plan says that this service is only 
covered once per tooth every five years. 
 
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 one of 
(D2950, D2952, D2954) once per tooth per 5 years.  
 
We looked at the file and Plan rules. The file indicates you received a prefabricated post and core in 
addition to crown (D2954) for tooth #31 on August 12, 2021, which is within five years of this request.  Based on this information, we decided that the Plan's rules for coverage of core buildup have not been met. 
Therefore, we decided that the Plan does not have to pre-approve core buildup (D2950) on tooth #31.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of lateral exostosis and reduction of 
osseous tuberosity (D7471 and D7485). 
 
You asked the Plan to pre-approve the removal of lateral exostosis and reduction of osseous tuberosity. You 
say that you would like reconsideration because this service is necessary in order for the enrollee's dentures to 
fit. The Plan denied your request. The Plan says these are 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 pre-approve the 
removal of lateral exostosis and reduction of osseous tuberosity (D7471 and D7485).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), first intraoral 
periapical x-ray (D0220), two additional intraoral periapical x-rays (D0230 x2), bitewing x-rays (D0274), and 
prophylaxis (D1110) provided on September 29, 2021 by a Medicare opt out provider. 
 
You asked the Plan to pay for the comprehensive oral evaluation, intraoral periapical x-rays, bitewing x-rays, 
and prophylaxis. You say that a relative referred you to this provider and you were not aware she did not accept 
Medicare until after the fact. You also say that you are living on a small social security benefit and have very 
little money. The Plan denied your request. The Plan says you received these services from a provider who 
chose not to receive Medicare funds. The Plan also says that the treating provider opted out of Medicare 
effective March 15, 2016, to March 15, 2022. 
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 
covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the comprehensive oral evaluation (D0150), first intraoral periapical x-ray 
(D0220), two additional intraoral periapical x-rays (D0230 x2), bitewing x-rays (D0274), and prophylaxis 
(D1110) provided on September 29, 2021 by a Medicare opt out provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an alignable system for a below-knee prosthesis. 
 
You asked the Plan to pre-approve 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. Medicare rules say that when a preparatory below knee prosthesis 
(L5510, L5520,L5530, L5540) is provided, prosthetic substitutions and/or additions of procedures and 
components are covered in accordance with the functional level assessment. 
 
We looked at the file and Medicare rules. The requested alignable system is not covered because the approved 
prosthesis is a preparatory protsthesis with a non-alignable system. The alignable system is not compatible with 
the approved prosthesis. Therefore, we decided that the Plan does not have to pre-approve an alignable system 
for a below-knee prosthesis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift chair. 
 
You asked the Plan to pre-approve a seat lift chair. You say that you would like the Plan to reconsider their 
denial.  The Plan denied your request. The Plan says they have now approved the seat lift mechanism; however, 
the seat left chair is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that seat lift chairs are not covered. Coverage is limited to 
a seat lift mechanism.  
Although a seat lift chair may be appropriate, Medicare does not cover this item and the Plan must provide 
coverage only for items that Medicare covers. Therefore, we decided that the Plan does not have to pre-approve 
a seat lift chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an opt-out dentist on October 13, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the rendering dentist has opted-out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program until March 9, 2022. Therefore, we decided that the Plan does not have 
to pay for dental services provided by an opt-out dentist on October 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the addition, endoskeletal, knee-shin system (L5845). 
 
You asked the Plan to pre-approve the addition, endoskeletal, knee-shin system. You say that this is medically 
reasonable and necessary. The Plan denied your request. The Plan says this part is unbundled and cannot be 
paid separately. 
 
The Plan must follow Medicare rules. Medicare rules say that L5925, L5930, L5845, L5848, L5850, L5856, 
L5857, L5858, L5859 are additional features and/or functions that do not describe a complete endoskeletal 
knee-shin system and must be used in combination with an L-code for a knee-shin system (L5610, L5611, 
L5613, L5616, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840). 
 
We looked at the file and Medicare rules. In this case, there is no documentation that endoskeletal knee-shin 
system will be provided with a required base knee shin system. Based on this information, we decided that 
Medicare rules for coverage of the addition, endoskeletal, knee-shin system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the addition, endoskeletal, knee-shin system (L5845).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the injection services coded 64447-59 and 64454-59 provided on 
October 4, 2021. 
 
You asked the Plan to pay for the injection services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says that these billed codes are not separately 
payable as they are included in other billed services. 
 
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 codes 
64447-59 and 64454-59 are both column II codes to column I code 01402; however, 64447-59 and 64454-59 
were both billed with a modifier. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the injection services. Our reviewer says that the 
documentation supports the use of the 59 modifiers to bypass NCCI edits. Our reviewer found the procedure 
report documents the injections billed were given for post-operative pain, with a start and stop time. This 
procedure would be separately payable with modifier 59 as billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection services have been met. Therefore, we decided that the Plan has to 
pay for the injection services coded 64447-59 and 64454-59 provided on October 4, 2021.  
 
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.