Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for radiological services provided on September 14, 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 the diagnosis code is invalid to the procedure 
modifier. 
 
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 find that the specific denial rationale offered by the Plan is not supported. 
While the line item for the right-sided imaging does include a pointer that identifies the left-sided knee pain, it 
also does point to the correct diagnosis for right-sided knee, as is also done with the left-sided line item. The 
Plan has not provided a rule that specifically supports denial of a claim simply due to a line item being 
associated with an inapplicable diagnosis as well as the correct diagnosis. Both conditions on the claim are 
documented in the record as are the two sides being injected. The Plan has not provided any alternate rationale. 
As such, we find that the denial of payment on this basis is not substantiated. 
 
 Therefore, we decided that the Plan has to pay for radiological services provided on September 14, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 1, 2021, 
to September 13, 2021, billed with HIPPS 3EB21. 
 
You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 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 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 home health services. Our reviewer says that the 
documentation does not support the HIPPS code billed. Our reviewer found the enrollee has a medical history 
including Parkinson's disease, falls and cervical spine pedicle fractures with weakness who received home 
health care services. In this case, the documentation doesnt support the correct PDPM HIPPS code was 
submitted by the organization. The diagnosis code reported by the therapist was not an accurate description of 
the functional impairment. 
 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for the home health services provided from September 1, 2021, to September 13, 2021, 
billed with HIPPS 3EB21.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) and an extraction 
(D7250) for tooth #18 provided on December 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had to see an oral surgeon to get the tooth 
removed because it broke when the dentist was removing it. The Plan denied your request. The Plan says your 
benefit for the requested items or services 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 panoramic radiographic image was exhausted on the date of service of October 19, 
2022, and your benefit for the extraction was exhausted on the date of service of December 05, 2022. 
Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) and an 
extraction (D7250) for tooth #18 provided on December 9, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the triamcinolone acetonide injection 
provided on November 29, 2022. 
 
You asked the Plan to waive the coinsurance for the triamcinolone acetonide injection. You say that you were 
told there was no cost for this injection. 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 for in-network Medicare Part B drugs. 
 
You have been asked to pay 20% coinsurance for the triamcinolone acetonide injection. This item/service falls 
within the in-network Medicare Part B 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 the triamcinolone acetonide injection provided on November 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiologic examination, hand; minimum of 3 views (X-ray) 
provided on February 11, 2022, billed with procedure code 73130. 
 
You asked the Plan to pay for the x-ray. You say that the medical records states that the service was outpatient. 
The Plan denied your request. The Plan says the wrong place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the Place of Service (POS) code assigned by the 
physician/practitioner for the professional component (PC) of a diagnostic service shall be the setting in which 
the enrollee received the technical component (TC) service.  
 
We looked at the file and Medicare rules. The services fall during the member's admission of an inpatient 
hospital stay. The claim reflects the 2-digit POS code 22 for on campus-outpatient hospital. The correct POS 
must be reflected on the claim. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a radiologic examination, 
hand; minimum of 3 views (X-ray) provided on February 11, 2022, billed with procedure code 73130.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) coded E0675 and 
half leg appliance coded E0673 billed for November 29, 2022. 
 
You asked the Plan to pay for 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 claims for E0675 will be denied as not 
reasonable and necessary.  
 
We looked at the file and Medicare rules. The services at issue are a PCD coded E0675. These services are 
denied by Medicare as not medically necessary. Given that the E0675 PCD is not covered, the half leg 
appliance billed with code E0673 is also not covered. Therefore, we decided that the Plan does not have to pay 
for the pneumatic compression device (PCD) coded E0675 and half leg appliance coded E0673 billed for 
November 29, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service December 6, 
2022. 
 You asked the Plan to pay for procedure code 76700. You say that the member had multiple exams done on 
this date of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into 
payment for code 93976. 
 
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 76700 
is a column II code to column I code 93976. 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 76700 billed for date of service December 6, 
2022.
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 
16, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the claim was billed correctly and should be 
paid. 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 December 16, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on December 9, 2022. 
 
You asked the Plan to pay for the medical services. You say that the patient had multiple exams on this date of 
service. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and 
was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on January 5, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the medical services have not been met. 
Therefore, we decided that the Plan does not have to pay for medical services provided on December 9, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services billed with HIPPS code 3FB11 
provided on May 17, 2021. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
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 HIPPS 3FB11 is not supported in the medical record. Specifically, no medical records were 
submitted to support the services billed. Therefore, the HIPPS code billed cannot be verified. Based on this 
information, we decided that Medicare rules for coverage of the home health services as billed have not been 
met. Therefore, we decided that the Plan does not have to pay for the home health services billed with HIPPS 
code 3FB11 provided on May 17, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76775 billed for date of service August 30, 
2022. 
 You asked the Plan to pay for procedure code 76775. You say that procedure code 76775 was not bundled with 
another procedure code on this date of service. The Plan denied your request. The Plan says payment for code 
76775 is bundled into payment for code 93976. 
 
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 76775 
is a column II code to column I code 93976. 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 76775 billed for date of service August 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 10, 2022, billed 
with procedure codes 71275 and 74174. 
 
You asked the Plan to pay for the medical services. You say that the services were approved before using place 
of service 22. The Plan denied your request. The Plan says the wrong place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the Place of Service (POS) code assigned by the 
physician/practitioner for the professional component (PC) of a diagnostic service shall be the setting in which 
the enrollee received the technical component (TC) service.  
 
We looked at the file and Medicare rules. The services fall between the member's admission and discharge of 
an inpatient hospital stay. The claim reflects the 2-digit POS code 22 for on campus-outpatient hospital. The 
correct POS must be reflected on the claim. 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 provided on August 10, 2022, billed with procedure codes 71275 and 74174.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mammography services received on October 5, 2022. 
 
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 you had primary insurance during the time of service. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer.  
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has The plan has 
confirmed that the primary insurance has a claim on file for this date of service. The primary insurance has 
confirmed the claim will be processed.. As the secondary insurer, the Plan cannot be held responsible for the 
services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan 
does not have to pay for mammography services received on October 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675) provided 
on October 24, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this item was medically 
necessary. The Plan denied your request. The Plan says this item was used outside the home and is not eligible 
for coverage. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for a pneumatic compression device (E0673, E0675) provided on October 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain pontic for tooth number 10 (D6240). 
 
You asked the Plan to pre-approve this dental item. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested item has 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 has been exhausted. Specifically, the Plans contract states that 
coverage is provided for pontics and retainer crowns but is limited to four units of a fixed denture per year.  The Plan previously authorized four units of a fixed denture for teeth number 6, 7, 8, 9. Therefore, you have 
exhausted the allowable benefit for the requested dental item at this time. Therefore, we decided that the Plan 
does not have to pre-approve a porcelain pontic for tooth number 10 (D6240).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on September 6, 2022. 
 
You asked the Plan to pay for the psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this service is not covered as the provider is a mental health counselor and 
not eligible for payment by the health Plan or original Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a Mental Health Counselor is not eligible to 
participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Mental Health Counselor. 
Medicare says that a Mental Health Counselor is not eligible to participate in the Medicare program. Therefore, 
we decided that the Plan does not have to pay for psychotherapy provided on September 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical boot (L3260) provided on September 30, 2022. 
 
You asked the Plan to pay for the surgical boot. You say that you went to the clinic. You say that you broke 
your toe. You also say that you did not know this would not be covered. The Plan denied your request. The 
Plan says the surgical boot is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that orthopedic footwear billed using code L3260 will 
be denied as noncovered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the surgical boot have not been met. Therefore, we decided that the Plan does not have to pay for 
the surgical boot (L3260) provided on September 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation/general anesthesia- first 15 minutes 
(D9222) and deep sedation/general anesthesia each 15 minutes increment(D9223). 
 
You asked the Plan to pre-approve anesthesia. You say that this should be covered. The Plan denied your 
request. The Plan says this is 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 deep 
sedation/general anesthesia- first 15 minutes (D9222) and deep sedation/general anesthesia each 15 minutes 
increment(D9223).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a localized delivery of antimicrobial agents (D4381) 
provided on October 7, 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 
localized delivery of antimicrobial agents (D4381) provided on October 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device appliances (E0673) provided on November 18, 2021.
You asked the Plan to pay for the pneumatic compression device appliances. You say that the place of service code for this product should rightfully be 12. The Plan denied your request. The Plan says that the denial of payment for these items is correct, because an invalid place of service code was used for this equipment.
The Plan must follow Medicare rules. The rules say that the place of service for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claims is considered the location where a beneficiary will primarily use the DMEPOS item and coverage for DMEPOS items is considered when the place of service is a specific approved location. We find that CPT code E0673 is not supported in the medical record. Specifically, the place of service of 24 submitted is not an approved place of service for durable medical equipment. Based on this information, we decided that Medicare rules for coverage of the pneumatic compression device appliances have not been met. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device appliances (E0673) provided on November 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for MRI provided on October 24, 2022. 
 
You asked the Plan to pay for MRI. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for MRI provided on 
October 24, 2022.