Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure codes 99601 and S9501 billed for dates of service March 21, 2022, to March 28, 2022.

You asked the Plan to pay for procedure codes 99601 and S9501. You say that these codes are valid and payable. The Plan denied your request. The Plan says the billed codes are invalid for Medicare purposes.

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 codes 99601 and S9501 have a Status Indicator of I on the Physician Fee Schedule. This means that procedure codes 99601 and S9501 are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code 99601 and S9501 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 99601 and S9501 billed for dates of service March 21, 2022, to March 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services provided on February 22, 2022, by a non-contracted provider.

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 were rendered by a non-contracted provider without prior 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. 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 surgical services provided on February 22, 2022, by a non-contracted provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical removal of a tooth (D7261) provided on July 12, 
2022. 
 
You asked the Plan to pay for the surgical removal of a tooth. 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 the 
surgical removal of a tooth (D7261) provided on July 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic 
x-ray (D0330) provided on June 27, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation and panoramic x-ray. You say that you had to 
find a new dentist and now you owe $145.00 for these services. You also say that you still need a deep 
cleaning. The Plan denied your request. The Plan says your benefits for the requested services have 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 benefits for the requested services were exhausted on date of service September 29, 2021. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and 
panoramic x-ray (D0330) provided on June 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the receiver (Monitor), dedicated, for use with therapeutic continuous glucose monitor system (K0554) and a supply allowance used with a therapeutic CGM device (K0553).

You asked the Plan to pre-approve the CGM and supply. You say that you want to appeal the approval of the Freestyle Libre. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for the requested CGM device.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of the CGM and supply have not been met. Therefore, we decided that the Plan does not have to pre-approve the receiver (Monitor), dedicated, for use with therapeutic continuous glucose monitor system (K0554) and a supply allowance used with a therapeutic CGM device (K0553).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on June 17, 2022, to June 18, 
2022 by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you were told by the dental group that they 
accepted your insurance, but they are out-of-network and do not participate in your plan. You say that you 
cannot afford these services. 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 the dental services provided on June 17, 2022, to June 18, 2022 by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for prophylaxis (D1110) provided by an out-of-network 
provider on June 23, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you have a secondary dental plan that 
should have covered the remaining balance. The Plan denied your request. The Plan says you are responsible 
for any charged amount above the Plans cost-sharing amount when your services are received from an out-of-
network provider. 
 
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 the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for prophylaxis (D1110) provided by an out-of-
network provider on June 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided by an out-of-network provider from March 17, 2022, through May 19, 2022.

You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior 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. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for psychotherapy provided by an out-of-network provider from March 17, 2022, through May 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for full mouth debridement (D4355), a limited oral evaluation 
(D0140), bitewings, and panoramic radiographic imaging (D0330), provided by an out-of-network provider on 
January 20, 2022, to March 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay at least 50% for 
these services. 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 full mouth debridement (D4355), a limited oral evaluation (D0140), bitewings, and panoramic 
radiographic imaging (D0330), provided by an out-of-network provider on January 20, 2022, to March 3, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on April 21, 2022.

You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing.

The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not separately payable. Laboratories should bill the facility directly for laboratory services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on April 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on May 25, 2022.

You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says the services were provided by a provider who chose not to receive Medicare funds.

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. Therefore, we decided that the Plan does not have to pay for physician's services provided on May 25, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 4, 2022.

You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing.

The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not separately payable. Laboratories should bill the facility directly for laboratory services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 4, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 11, 2022.

You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing.

The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not separately payable. Laboratories should bill the facility directly for laboratory services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 11, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service April 20, 2022.

You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. The Plan denied your request. The Plan says code 83789 is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine specimens utilized for drug testing should not separately bill the validity testing.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service April 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient observation services provided on 
January 7, 2022. 
 
You asked the Plan to waive the copayment for outpatient observation services. You say that you go to the 
podiatrist on a monthly basis to have your toenails clipped and treated. You also say nothing about this visit 
was unique. 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 $240 
copayment for the outpatient observation per stay.  
 
 
  You have been asked to pay $180.86, which is less than the $240 copayment for outpatient observation 
services. This item/service falls within the outpatient observation per stay 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 outpatient observation services provided on January 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that prior to hospitalization the enrollee was doing daily 
activities on her own and without proper rehabilitation she will deteriorate. The Plan denied your request. The 
Plan says based on Medicare guidelines the inpatient rehabilitation facility services you are requesting do not 
meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found the enrollee was admitted for coronary artery bypass. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the enrollee has a need for physical or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service May 2, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. The Plan denied your request. The Plan says code 99153 
is not payable in the facility setting. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service May 2, 2022, billed with 
code 99153.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat Orthovisc injection (J7324). 
 
You asked the Plan to pre-approve Orthovisc. You say that the requested injection is medically necessary for 
the enrollee. The Plan denied your request. The Plan says a repeat injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat series of viscosupplement therapy is 
considered reasonable and necessary when the patient has experienced improvement in pain and functional 
capacity following the previous series of injections. 
 
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 Orthovisc. Our reviewer says that a 
repeat Orthovisc injection is not medically necessary. Our physician reviewer found the provided records do not indicate that the enrollee has experienced improvement in pain and functional capacity following the 
previous series of Orthovisc injections. Therefore, the reviewer found that a repeat injection is not medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a repeat Orthovisc injection (J7324).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergent transportation benefits. 
 
You asked the Plan to pre-approve additional non-emergent transportation benefits. You say that you need 
extra trips due to having a lot of appointments that are scheduled out to the end of the year. The Plan denied 
your request. The Plan says the EOC clearly states they cover 100 one-way trips per calendar year. The Plan 
also says that the 101sst and beyond is not a covered benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 100 one-way trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergent transportation benefits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) (E0675) provided 
on November 25, 2021. 
 
You asked the Plan to pay for the PCD. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
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. Per L33829, the requested PCD (E0675) is not medically reasonable 
and necessary, and therefore not covered. Based on this information, we decided that Medicare rules for 
coverage of the PCD have not been met. Therefore, we decided that the Plan does not have to pay for the 
pneumatic compression device (PCD) (E0675) provided on November 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a digital, binaural hearing aid (V5260). 
 
You asked the Plan to pre-approve a digital, binaural hearing aid (V5260). You say that there is no provider 
within driving distance of this patient that honors the $1,000 per ear, per year, coverage. The Plan denied your 
request. The Plan says there are several Plan participating facilities near your home where you can receive 
these services. 
 
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 only when the services are received from any network hearing or hearing aid provider.  
 
 
  We looked at the file, and the Plan's rules. The Plan rules state that they will only cover services when they are 
received from a network provider. The record shows that there are in-network providers available within a 
reasonable distance. Based on this information, we decided that the Plan's rules for coverage of a digital, 
binaural hearing aid (V5260) have not been met. Therefore, we decided that the Plan does not have to pre-
approve a digital, binaural hearing aid (V5260).