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

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service November 
14, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service November 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 2, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported as 
billed. The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on September 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on October 31, 2022. 
 
You asked the Plan to pay for self-administered drugs. You say that the drug was part of a test you took and 
was not self-administered. The Plan denied your request. The Plan says self-administered drugs are not 
covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
on October 31, 2022.  
 Benefits for self-administered drugs 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Orthovisc injections (J7324). 
 
You asked the Plan to pay for Orthovisc injections. You say that this service is medically necessary. The Plan 
denied your request. The Plan says the documentation provided does not support the requested services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of Orthovisc injections have been met. 
No clinical records were provided to support this service. Therefore, we decided that the Plan does not have to 
pay for Orthovisc injections (J7324).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care, primary care visits 
and a specialist office visit provided on May 3, 2022, to June 13, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care, primary care visits and a specialist 
office visit. 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 $395 
copayment per day for days 1-5 for inpatient hospital care and a $15 copayment and a $50 copayment per visit for physician/practitioner services/primary care physician (PCP) services/specialist.  
 
You have been asked to pay a $395 copayment per day for days 1-5 for inpatient hospital care and a $15 
copayment and a $50 copayment per visit for primary care visits and a specialist office visit. The total amount 
for inpatient hospital care is $790 ($395 x 2 days = $790). The total amount you are being asked to pay for 
primary care is $30 ($15 x 2 visits = $30). The total amount you are being asked to pay for all services is ($790 
+ $30 + $50 = $870). 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 inpatient hospital care, primary 
care visits and a specialist office visit provided on May 3, 2022, to June 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 12 units of procedure code 60220 billed for date of service 
August 24, 2021, to August 25, 2021. 
 
You asked the Plan to pay for 12 units of procedure code 60220. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the number of units billed 
exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 60220 is 1. The MAI value for this code is 3. You billed 13 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 60220 have not been met. Therefore, we decided that the 
Plan does not have to pay for 12 units of procedure code 60220 billed for date of service August 24, 2021, to 
August 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain fused to high noble metal tooth #'s 
7, 8 and 9 (D2750). 
 
You asked the Plan to pre-approve the crown - porcelain fused to high noble metal tooth #'s 7, 8 and 9 (D2750). 
You say that you are having discomfort. The Plan denied your request. The Plan says the service is not 
medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the crown - 
porcelain fused to high noble metal tooth #'s 7, 8 and 9 (D2750) when the services are medically necessary and 
reasonable.  
 
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 the crown - porcelain fused to high 
noble metal tooth #'s 7, 8 and 9 (D2750). Our reviewer says that the documentation provided was inadequate to 
determine if the criteria for coverage have been met.  Our physician reviewer found the radiographs were not of diagnostic quality and there was no narrative 
indicating why the crown restorations were needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown - porcelain fused to high noble metal tooth #'s 7, 8 and 9 (D2750) 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown - porcelain fused 
to high noble metal tooth #'s 7, 8 and 9 (D2750).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF care to gain additional 
independence. The Plan denied your request. The Plan says an IRF admission is not medically necessary. 
 
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 that the enrollee does not require the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollees care needs can be met at a lower level of care. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood count; complete (CBC) (85025), thyroid 
stimulating hormone (TSH) (84443), and hemoglobin; glycosylated (A1C) (83036) testing provided on June 
30, 2022. 
 
You asked the Plan to pay for the CBC, TSH and A1C testing. You say that this testing should be covered. The 
Plan denied your request. The Plan says screening tests are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the CBC, TSH and A1C testing, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the blood count; complete (CBC) (85025), thyroid stimulating hormone (TSH) (84443), and 
hemoglobin; glycosylated (A1C) (83036) testing provided on June 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) provided on July 9, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99203) provided on July 9, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management provided on August 01, 2022. 
 
You asked the Plan to pay for chronic care management. You say that you are appealing the claim payment 
denial. 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 chronic care 
management provided on August 01, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency care visit provided on 
October 16, 2022. 
 
You asked the Plan to waive the copayment for an emergency care visit. You say that you are disputing the 
share cost. 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 $90 
copayment for Emergency care. 
 
You have been asked to pay a $90 copayment for an emergency care visit. This item/service falls within the 
Emergency care 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 emergency care 
visit provided on October 16, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the subsequent nursing facility care (99308) provided from August 16, 
2022, to August 30, 2022. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that you would like payment to be 
released for the services provided. The Plan denied your request. The Plan says that there is inadequate 
documentation to support the medical necessity for repeat professional visits at a frequency exceeding 
Medicare guidelines. 
 
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 records do not support that the medical necessity for repeat professional 
visits. Medical records were not provided with this case, and there is no documentation showing the Plan 
attempted to obtain medical records. This means that the Plan has not provided a valid reason for denying 
payment of the subsequent nursing facility care. It is the burden of the Health Plan to substantiate their denial 
with evidence. In this case, the denial has not been substantiated so we must find in your favor. Therefore, we 
decided that the Plan has to pay for the subsequent nursing facility care (99308) provided from August 16, 
2022, to August 30, 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 coinsurance applied to bitewing x-rays (D0270) provided 
on November 28, 2022. We also decided that the Plan does not have to pay for a pre-diagnostic test (D0431), 
the localized delivery of antimicrobial agents (D4381), gingival irrigation (D4921), drugs or medicaments 
dispensed in the office for home use (D9630), a limited oral evaluation (D0140), the first intraoral periapical 
radiographic image (D0220), an additional periapical radiographic image. (D0230) provided on September 27, 
2022, to November 28, 2022. 
 
You asked the Plan to waive the coinsurance applied to the bitewing x-rays. You also asked the Plan to pay for 
the dental services represented by codes D0431, D4381, D4921, D9630, D0140, D0220, and D0230.  You say 
that you should be compensated for the charges you paid out-of-pocket to your dentist. The Plan denied your 
request. The Plan says the coinsurance was appropriately applied to the bitewing x-rays provided. The Plan 
says that the dental services represented by codes D0431, D4381, D4921, D9630, D0140, D0220, and D0230 
are not covered under the enrollees benefits.  
 
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 bitewing x-rays provided out-of-network. 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 50% coinsurance for the bitewing x-rays. The bitewing x-rays were received 
from an out-of-network provider. This service falls within the bitewing x-rays provided out-of-network 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 applied to bitewing x-rays (D0270) provided on 
November 28, 2022.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the dental services represented by 
codes D0431, D4381, D4921, D9630, D0140, D0220, and D0230 are not among those covered under this 
benefit. Therefore, we decided that the Plan does not have to pay for a pre-diagnostic test (D0431), the 
localized delivery of antimicrobial agents (D4381), gingival irrigation (D4921), drugs or medicaments 
dispensed in the office for home use (D9630), a limited oral evaluation (D0140), the first intraoral periapical 
radiographic image (D0220), an additional periapical radiographic image. (D0230) provided on September 27, 
2022, to November 28, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on August 23, 2022. 
 
You asked the Plan to pay for nursing facility care. You say that you are appealing the claim payment denial. 
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 nursing facility care 
provided on August 23, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for the skilled nursing facility (SNF) services provided from July 23, 2022, 
to August 10, 2022. 
 
You asked the Plan to pay for the SNF services. You say that you are requesting the Plan to pay for the SNF 
services. The Plan denied your request. The Plan says that the hospital stay was denied. 
 
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 Plan did not provide us with medical records or with evidence 
of having made reasonable attempts to obtain medical records from the SNF provider. Without this necessary 
documentation, the Plan has not substantiated their denial reason. Therefore, we decided that the Plan has to 
pay for the skilled nursing facility (SNF) services provided from July 23, 2022, to August 10, 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 injection provided on May 06, 2022. 
 
You asked the Plan to waive the coinsurance for injection. You say that you are disputing the share cost. 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 Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for injection. This item/service 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 injection provided 
on May 06, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with code 0089U-XS for June 
23, 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 -XS modifier is not supported. 
 The Plan must follow Medicare rules. The rules state that providers may bill services with the -XS modifier if 
the service billed with the modifier indicates a distinct procedural service.   
 
The medical records provided do not show that the service billed with the -XS modifier is a distinct procedural 
service. Specifically, the documentation contains only one result for the testing. Based on this information, we 
decided that Medicare rules for coverage of services billed with a -XS modifier have not been met. Therefore, 
we decided that the Plan does not have to pay for the laboratory services billed with code 0089U-XS for June 
23, 2022.