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

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 4, 
2022. 
 You asked the Plan to pay for procedure code 70450. 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 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 November 4, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on November 14, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you are not obligated to pay the 
difference of the copay. 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 $115 
copayment for outpatient radiological diagnostic services, not including X-rays, performed in a physicians 
office or at a free-standing facility.  
 
You have been asked to pay a $115 copayment for an ultrasound. This item/service falls within the outpatient 
radiological diagnostic services 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 ultrasound provided on November 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on September 13, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for wound care supplies provided by an out-of-network provider. You say that the 
services were medically necessary. The Plan denied your request. The Plan says the services were rendered 
out-of-network and 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 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 wound care supplies provided on September 13, 
2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve resin-based composite - one surface, posterior tooth #'s 
29 and 30 (D2391), and periodontal scaling and root planing - one to three teeth per quadrant tooth # 25 32 
(D4342). 
 
You asked the Plan to pre-approve codes D2391 and D4342. You say that the dental services could not be done 
due to COVID-19 protocols. You also say that you could not see your dentist for two years. The Plan denied 
your request. The Plan says these services are not covered under the benefit package. 
 
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 
resin-based composite - one surface, posterior tooth #'s 29 and 30 (D2391), and periodontal scaling and root 
planing - one to three teeth per quadrant tooth # 25 32 (D4342).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4253 billed for date of service July 15, 
2022. 
 
You asked the Plan to pay for procedure code A4253. You say that the services were medically necessary. 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 A4253 is 1. The MAI value for this code is 3. You 2 units of this code, 
exceeding the MUE. There is insufficient evidence showing that the excess units were provided, correctly 
coded, and medically necessary. Based on this information, we decided that Medicare rules for coverage have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code A4253 billed for 
date of service July 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation - per site 
(D7953), and gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth (D4212). 
 
You asked the Plan to pre-approve codes D7953 and D4212. You say that the procedures are needed to save 
your teeth. You also say that several dentists have recommended the same services. The Plan denied your 
request. The Plan says these services are not covered under the benefit package. 
 
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 a 
bone replacement graft for ridge preservation - per site (D7953), and gingivectomy or gingivoplasty to allow 
access for restorative procedure, per tooth (D4212).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says a pneumatic compression 
device is not covered for the prevention of deep vein thrombosis post-surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 13, 2022, billed with 
codes 81455, 81479, 81479, 81301, and 81194. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 13, 2022, billed with codes 81455, 81479, 81479, 81301, and 81194.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. The Plan denied your request. The Plan says you do not 
meet the criteria established to receive SSBCI benefits for 2023. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have one of 
the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to 
pre-approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthovisc (J7324). 
 
You asked the Plan to pre-approve orthovisc. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says the drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 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 the 
drug is not medically necessary. Our physician reviewer found there is no documentation that the patient has 
experienced a failure of or has a contraindication to intra-articular glucocorticoid injections as required. 
 
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 orthovisc (J7324).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a water circulating heating pad with pump (E0217RR) 
provided from May 27, 2022, through June 21, 2022. 
 
You asked the Plan to pay for a water circulating heating pad with pump. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that it has not been established that a moist electric 
heating pad (E0215) or water circulating heat pad with pump (E0217) is reasonable and necessary compared to 
a standard electric heating pad (E0210); therefore, if code E0215 or E0217 is provided it will be denied as not 
reasonable and necessary.  
 
   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a water circulating heating pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for a water circulating heating pad with pump (E0217RR) provided from May 27, 2022, 
through June 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an automatic external defibrillator (K0606) provided on 
September 6, 2021. 
 
You asked the Plan to pay for an automatic external defibrillator. You say that the service was medically 
necessary. The Plan denied your request. The Plan says Medicare denies a claim for untimely filing if the 
receipt date applied to the claim exceeds 12 months or 1 calendar year from the date the services were 
furnished. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for an automatic external defibrillator was not filed until November 7, 2022. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for an automatic external defibrillator (K0606) 
provided on September 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a therapeutic continuous glucose 
monitor (CGM) (K0553) provided on November 19. 2022. 
 
You asked the Plan to pay for the CGM supply allowance. You say that you would like this claim to be 
considered for payment. The Plan denied your request. The Plan says the proof of delivery shows the shipping 
date was November 11, 2022, and the delivery date was November 14, 2022. The Plan also says that both of 
these dates are prior to the date of service of November 19, 2022, billed on the claim. 
 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 for the supplies provided in this case. Specifically, there is 
no valid date of delivery which matches the date of service for this claim, and no itemized list that shows the 
items that were delivered. Therefore, we decided that the Plan does not have to pay for the supply allowance 
for a therapeutic continuous glucose monitor (CGM) (K0553) provided on November 19. 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vertical bitewings - 7 to 8 radiographic images (D0277), and 
topical application of fluoride varnish (D1206) provided on November 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services should be covered by the dental 
benefit. The Plan denied your request. The Plan says your benefit for the topical application of fluoride varnish 
has already been exhausted, and the vertical bitewings radiographic images are 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, vertical bitewings - 7 to 8 radiographic 
images (D0277) is not covered under this benefit. The record shows your benefit for the topical application of 
fluoride varnish (D1206) was exhausted on date of service May 5, 2022. Therefore, we decided that the Plan 
does not have to pay for vertical bitewings - 7 to 8 radiographic images (D0277), and topical application of 
fluoride varnish (D1206) provided on November 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyewear provided on September 29, 2022. 
 
You asked the Plan to pay for the eyewear. You say that all the charges on the claim are for eyeglasses and you 
have a $250 allowance. The Plan denied your request. The Plan says the benefit has been exhausted. 
 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 and reimburses up to $250. 
 
We looked at the file and the Plan's rules. Specifically, the Plan has reimbursed a total of $250 towards vision 
services which exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage 
of the eyewear have not been met. Therefore, we decided that the Plan does not have to pay for the eyewear 
provided on September 29, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insulin degludec. 
 
You asked the Plan to pre-approve the insulin degludec. You say that the drug is medically necessary. The Plan 
denied your request. The Plan says this is a self-administered drug. 
 
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 pre-approve the insulin degludec.  
 
Benefits for the insulin degludec 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 provided on March 20, 2022. 
 
You asked the Plan to pay for procedure code 99285. You say that you would like the Plan to reconsider their 
denial of payment. 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 April 8, 2022. 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 procedure code 99285 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99285 provided on March 20, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on September 8, 
2022. 
 You asked the Plan to pay for the outpatient services. You say that the details of the denial are vague. The Plan 
denied your request. The Plan says the claim denied correctly. 
 
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 looked at the file and the rules. We find that code J2323, which has a status indicator of K, was not billed 
with a payable procedure. The remaining codes may be eligible for payment once the J2323 edit has been 
corrected. Based on this information, we decided that Medicare rules for coverage of the outpatient services 
have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services 
provided on September 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Gemtesa. 
 
You asked the Plan to pre-approve the Gemtesa. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says this is a self-administered drug. 
 
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 pre-approve the Gemtesa.  
 
Benefits for the Gemtesa 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 pre-approve Methylprednisolone. 
 
You asked the Plan to pre-approve Methylprednisolone.. You say that the drug is medically necessary. The 
Plan denied your request. The Plan says this is a self-administered drug. 
 
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 pre-approve Methylprednisolone.  
 
Benefits for Methylprednisolone. 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 
16, 2022. 
 
You asked the Plan to pay for procedure code 70450. 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 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 November 16, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203), and coronavirus test (87811) 
provided on September 2, 2022. 
 
You asked the Plan to pay for the physician services. You say that this should be paid. The Plan denied your 
request. The Plan says the provider's signature is missing from the medical records that were provided. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare requires that services 
provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in 
accordance with Medicare's policies. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physician services have not been met. Specifically, the documentation submitted does not 
include a valid signature from the persons responsible for the care of the beneficiary. We find that there is no 
provider signature on the medical records. Therefore, we decided that the Plan does not have to pay for the 
office visit (99203), and coronavirus test (87811) provided on September 2, 2022.