Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from August 5, 2022, through 
August 31, 2022. 
 
You asked the Plan to pay for the home health services. You say that you feel that this should be paid. The Plan 
denied your request. The Plan says that it was decided to pay some of the claim; however, the first month was 
not billed correctly. 
 
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 only rationale given for the dates of service remaining at issue is that the 
claim was billed incorrectly. Review of the 983-page case file did not locate any narrative from the Plan 
explaining the billing issue which justified the denial. As such, the denial of payment is not substantiated. 
Therefore, we decided that the Plan has to pay for the home health services provided from August 5, 2022, 
through August 31, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, and 87798 billed for date of 
service March 25, 2022. 
 
You asked the Plan to pay for procedure codes 87481, 87653, and 87798. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says payment for code 87481, 87653, and 87798 is 
bundled into payment for code 87801. 
 
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 
87481, 87653, and 87798 are column II codes to column I code 87801. 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 87481, 87653, and 87798 
billed for date of service March 25, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a custom shaped protective cover, below knee (L5704). 
 
You asked the Plan to pre-approve a custom shaped protective cover. You say that the enrollee needs the K3 
for their active lifestyle. The Plan denied your request. The Plan says that the requested items are not covered. 
 
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. Specifically, the file does not support the Plans denial. There was no 
documentation provided that indicates the type of base prosthesis that had been approved for the enrollee. 
Therefore, we decided that the Plan has to pre-approve a custom shaped protective cover, below knee (L5704).  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic test provided on 
September 1, 2022. 
 
You asked the Plan to waive the copayment for an outpatient diagnostic test. You say that you disagree with 
the copayment. 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 $95 
copayment for outpatient diagnostic test.  
 
You have been asked to pay a $95 copayment for an outpatient diagnostic test. This item/service falls within 
the outpatient diagnostic test 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 
outpatient diagnostic test provided on September 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingivectomy (D4212) for tooth #3 provided on September 
12, 2022. 
 
You asked the Plan to pay for the dental service. You say that you are appealing the denied dental service. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because gingivectomy 
is 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
gingivectomy (D4212) for tooth #3 provided on September 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve axillary padding, neoprene loop (L7499 x2). 
 
You asked the Plan to pre-approve the axillary padding. You say that the enrollee needs this prosthesis for 
everyday tasks. The Plan denied your request. The Plan says this is a miscellaneous code and cannot be used if 
an appropriate code is available or if this is unbundled.  

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve axillary padding, neoprene loop (L7499 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service August 5, 
2021. 
 
You asked the Plan to pay for procedure code 99053. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 99053 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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service August 5, 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 October 16, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 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 October 16, 
2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for radiological services provided on October 12, 2022. 
 
You asked the Plan to pay for radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says that payment for this service may have been 
provided in a previous payment. 
 
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. We have not been provided with sufficient documentation to make a decision of 
payment. Specifically, we have not been provided with an Explanation of Benefits in which the plan states that 
the claim was previously made for this service, which was noted as the reason the claim was denied. Therefore, 
we decided that the Plan has to pay for radiological services provided on October 12, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for denosumab injection and injection of drug 
provided on June 13, 2022. 
 
You asked the Plan to waive the coinsurance for denosumab injection and injection of drug. You say that you 
were told the injection would be covered in full, so you should not have to pay the coinsurance. 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 20% 
coinsurance of the total cost for Medicare-covered drugs and administration.  
 
  You have been asked to pay $270.39 for denosumab injection and injection of drug.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
June 13, 2022 denosumab injection $1,275.60 20% $255.12 
June 13, 2022 injection of drug $76.34 20% $15.27 
TOTAL:    $270.39 
 
The denosumab injection falls within the Medicare Part B prescription drugs benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for denosumab injection and injection of drug provided on June 13, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the somatosensory testing (95938) provided on August 12, 
2022. 
 
You asked the Plan to pay for the somatosensory testing. You say that this service meets the medical necessity 
guidelines for coverage. The Plan denied your request. The Plan says charges for or in connection with services 
or supplies that are, as determined by the Plan, considered to be experimental or investigational are excluded 
from coverage under the enrollee's plan. 
 
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 pay for the somatosensory testing. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is a male with cervical spondylosis myelopathy with bilateral numbness 
and tingling in the upper extremities who underwent posterior cervical fusion surgery. Somatosensory testing 
(95938) was also provided during this surgery on August 12, 2022. Our reviewer found that current literature 
does not support this specific testing for this specific surgery. Evidence does not show post-operative benefit 
with its intraoperative use. Our physician reviewer also found that this request for somatosensory testing will 
be considered not medically necessary for this enrollee's condition. 
 
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 somatosensory testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the somatosensory testing (95938) provided on August 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodontal evaluation (D0180), and a diagnostic 
consultation (D9310) 
 
You asked the Plan to pay for the dental services. You say that you feel like you are being taken advantage of. 
The Plan denied your request. The Plan says the denied services have been processed correctly. 
 
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 D0180 was exhausted on date of service November 4, 2022. D9310 is not a covered 
dental benefit. Therefore, we decided that the Plan does not have to pay for a periodontal evaluation (D0180), 
and a diagnostic consultation (D9310)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pacemaker (33208). 
 
You asked the Plan to pre-approve a pacemaker. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is 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 a pacemaker. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is insufficient documentation to support the medical necessity for the requested cardiac pacemaker 
in this patients 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 a pacemaker have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a pacemaker (33208).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two additional periapical x-rays provided on September 
21, 2022. 
 
You asked the Plan to pay for the dental services. You say that that this service was required to get x-rays of 
your entire mouth and should be covered. 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 September 21, 2022, 
when the Planned paid for the first periapical x-ray. Therefore, we decided that the Plan does not have to pay 
for the two additional periapical x-rays provided on September 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy visit provided on September 29, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy visit. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 psychotherapy visit provided on September 29, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for care management services provided on October 13, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for care management services. You say that the enrollee could not choose an in-
network provider. The Plan denied your request. The Plan says these services were not authorized. 
 
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 care management services provided on October 
13, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental office visit for observation (D9430) provided on 
November 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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 a dental 
office visit for observation (D9430) provided on November 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for wound debridement provided from 
September 16, 2022, to October 21, 2022. 
 
You asked the Plan to waive the copayments for wound debridement. You say that you were initially charged a 
$45 copayment for the first visit for this procedure. 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 $290 
copayment for each in-network Medicare-covered outpatient hospital facility visit.  
 
You have been asked to pay a $290 copayment for each wound debridement procedure. You have been asked 
to pay a total of $1,160 ($290 copayment x 4 visits = $1,160). This item/service falls within the outpatient 
surgery 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 wound debridement 
provided from September 16, 2022, to October 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a light weight powered wheelchair purchased on September 
18, 2021. 
 
You asked the Plan to pay for a light weight powered wheelchair. You say that you submitted the 
documentation twice, but it was not received, so I sent it again. The Plan denied your request. The Plan says 
your request is past the 12-month filing period required by the plan and your appeal request has been denied. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for a light weight powered wheelchair was not filed until October 15, 2022. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for a light weight powered wheelchair purchased on 
September 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve enteral nutrition (Ensure) (B4152). 
 
You asked the Plan to pre-approve Ensure. You say that you were advised by a plan representative that due to 
your condition, you qualify for additional benefits. You say that you would like up to $70 applied to your over-
the-counter benefit every three months for the Ensure. You also say that this is just as important as the 
medications you are prescribed. The Plan denied your request. The Plan says Ensure is a benefit exclusion. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve enteral nutrition (Ensure) (B4152).