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

 
We decided that the Plan does not have to pay for two additional units of procedure code 93971 provided to the 
enrollee on July 20, 2022. 
 
You asked the Plan to pay for the additional units. You say that this should be paid for. The Plan denied your 
request. The Plan says there is a Medically Unlikely Edit (MUE) value of 1, but 3 units were 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 93971 is "Duplex scan of extremity veins including 
responses to compression and other maneuvers; unilateral or limited study." 
 
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 additional units. Our reviewer says that the services at 
issue in this case were not supported by the medical records. Our reviewer found that a review of the records 
shows three copies of the same report - left lower extremity ultrasound with doppler, compression and 
augmentation. All of these maneuvers are standard for a lower extremity venous ultrasound. Only one billable 
unit for CPT 93971 is in the records. The other two charges are duplicates and should not be paid. 
 
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 additional units have not been met. Therefore, we decided that the Plan does 
not have to pay for two additional units of procedure code 93971 provided to the enrollee on July 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87651, 87150, and 87798-91 billed for date 
of service September 28, 2021. 
 
You asked the Plan to pay for procedure codes 87651, 87150, and 87798-91. You say that you have submitted 
medical records to support payment. The Plan denied your request. The Plan says payment for codes 87651, 
and 87150 are bundled into payment for codes 87801 and 87500. The Plan also says that the 91 modifier 
appended to code 87798 is not supported in the medical record. 
 
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 
87651 and 87150 are column II codes to column I codes 87801 and 87500. This claim has not been billed with 
an appropriate modifier to bypass the edit.  
 
In relation to code 87798-91 (which is testing for infections agent antigen detection), Medicare rules state that 
the 91 modifier is to be used when a test is performed more than once on the same day for the same patient. We 
looked at the records you submitted, and there is no indication that you performed a repeat of this test on this 
date of service. Therefore, appropriate use of the 91 modifier cannot be confirmed. 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 87651, 87150, and 87798-91 billed for date of service September 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 provided on August 4, 2022. 
 
You asked the Plan to pay for procedure code J3490. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 We looked at the file and Medicare rules. Payment for the requested drugs (J3490) is included in the global 
surgery payment for the procedure (64490) provided on the same date. Separate payment cannot be made for 
the requested drugs. Based on this information, we decided that Medicare rules for coverage of the drugs have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code J3490 provided on 
August 4, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient behavioral health office visits to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve outpatient behavioral health office visits to be provided by an OON 
provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-
network providers that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 
outpatient behavioral health office visits to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement, muscle and/or fascia (includes epidermis, 
dermis, and subcutaneous tissue, if performed); first 20 sq cm or less provided to the enrollee on July 20, 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 per the procedure report, the debridement of the muscle was performed at the same location as 
the as the EpiFix skin substitute application. 
 
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 11043 is "Debridement, muscle and/or fascia (includes 
epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that per the National Correct Coding 
Initiative Policy Manual, Chapter III, debridement of a skin wound (e.g., CPT codes 11000, 11042-11047, 
97597, 97598) before a graft/skin substitute is included in the skin graft/skin substitute procedure (CPT codes 15050-15278) and shall not be reported separately. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if 
performed); first 20 sq cm or less provided to the enrollee on July 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device (E0730) provided June 12, 2022. 
 
You asked the Plan to pay for the TENS device. You say that the prescribing physician recommends a(n) 
extended/ lifetime use of equipment as they are diagnosed with chronic pain and compromised mobility 
without the option for surgical correction. The Plan denied your request. The Plan says evidence of 
misrepresented service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid proof of delivery, or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the proof of delivery did not include an order 
number or details to corroborate the delivery ticket submitted. Also, the proof of delivery is not itemized to 
indicate the specific supplies. Also, there is no evidence of an established relationship between the enrollee and 
the ordering physicianThe record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the 
transcutaneous electrical nerve stimulation (TENS) device (E0730) provided June 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine (90750), and administration (90471) 
provided on October 14, 2022. 
 
You asked the Plan to pay for the immunization services. You say that you were told that this vaccine was 
covered by your insurance. You also say that you thought it would be covered at a doctor's office before it is 
covered at the pharmacy. The Plan denied your request. The Plan says the shingles vaccine is not covered 
under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunization 
services. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the immunization 
services. Therefore, we decided that the Plan does not have to pay for the shingles vaccine (90750), and 
administration (90471) provided on October 14, 2022.  
 Benefits for the immunization services may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pre-approve the ambulance service, basic life support, emergency transport 
provided on September 7, 2022. 
 
You asked the Plan to pre-approve the ambulance service, basic life support, emergency transport. You say that 
you made two trips to the member on the same day and would like to be paid for the second trip to retrieve the 
member. The Plan denied your request. The Plan says that the claim was processed correctly with the denial, 
not covered when member is inpatient. 
 
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 records provided did not demonstrate that the transportation in 
dispute was provided from the inpatient hospital to another location for treatment. The records from the 
provider show that the transportation services in dispute were provided from the enrollees home. Therefore, 
we decided that the Plan has to pre-approve the ambulance service, basic life support, emergency transport 
provided on September 7, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a resin-based composite (D2391) for tooth 
#19 and pay for an intraoral radiographic image (D0230) provided on October 13, 2022. You asked the Plan to waive the copayment for a resin-based composite and pay for the intraoral radiographic 
image. You say that you cannot afford to pay for the dental services. 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 50% 
coinsurance for resin-based composite (white)  anterior (front) or posterior (back). The total amount allowed 
for the resin-based composite was $119 and the coinsurance amount was $59.50 ($119 total amount x 50% 
coinsurance). 
 
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. 
 
You have been asked to pay a $59.50 coinsurance for the resin-based composite. This item/service falls within 
the mandatory supplemental dental 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. Though the Plan offers a dental benefit in excess of Medicare coverage, certain 
limitations apply. The record shows your benefit for the intraoral radiographic images was exhausted on the 
date of service of October 13, 2022. Therefore, we decided that the Plan does not have to waive the copayment 
for a resin-based composite (D2391) for tooth #19 and pay for an intraoral radiographic image (D0230) 
provided on October 13, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on September 2, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that the services provided to the enrollee were 
medically necessary. The Plan denied your request. The Plan says the rendering provider is an OON provider 
and there was no approved authorization. 
 
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. Although the Plan has limited 
network providers in the enrollees service area 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 nursing facility care provided on September 2, 2022, by an out-of-network 
(OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 6, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be covered. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the laboratory services provided on June 6, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology procedures of the lower extremities 
provided on May 10, 2022. 
 
You asked the Plan to pay for diagnostic radiology procedures of the lower extremities. The Plan denied your 
request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services 
related or unrelated to the members terminal condition. The Medicare hospice benefit, through fee-for-service 
Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. 
During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to 
the terminal illness until the first day of the month following the month in which hospice was revoked or 
discharged. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for diagnostic radiology procedures of the lower extremities 
provided on May 10, 2022.
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 13, 2020, to September 15, 2021. 
 
You asked the Plan to pay for the dental services. You say that you are on a limited income. The Plan denied 
your request. The Plan says the dental services were received from an out-of-network provider and are not 
covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided by an out-of-network provider on January 13, 2020, to September 15, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on June 23, 2022. 
 
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says 
the member is enrolled in Hospice, please submit claim directly to Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on June 4, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for a domiciliary or rest home 
visit provided on June 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction (92015) provided on June 29, 2022. 
 
You asked the Plan to pay for an eye refraction. You say that the service should be covered. The Plan denied 
your request. The Plan says the service at issue is not a covered benefit when performed during a medical eye 
examination.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when The Plan covers this service when it is performed by a 
participating provider and as a routine screening. 
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of an eye refraction have not been met. Specifically, eye refraction is only covered by the Plan when 
it is performed as part of a routine screening by a participating provider. This service was performed for 
medical vision purposes, and therefore is not a covered benefit. Therefore, we decided that the Plan does not 
have to pay for an eye refraction (92015) provided on June 29, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on 
October 27, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that this was a 
preventative service. 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 $200 
copayment for each Medicare-covered ambulatory surgical center visit. 
 
 You have been asked to pay a $200 copayment for the diagnostic colonoscopy. This item/service falls within 
the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers benefit category because it was diagnostic rather than preventative. 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 the diagnostic colonoscopy provided on October 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (D0274), and intraoral images (D0230) provided 
on August 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that these x-rays were medically necessary. 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 January 11, 2022. 
Therefore, we decided that the Plan does not have to pay for bitewings (D0274), and intraoral images (D0230) 
provided on August 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a filling (D2331) 
 
You asked the Plan to pay more 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 your $1,000 dental benefit maximum 
allowance 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 30, 2021. 
Therefore, we decided that the Plan does not have to pay more for a filling (D2331)