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

 
We decided that the Plan does not have to pay for the self-administered drugs provided on May 9, 2022, and 
May 10, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you were in the emergency department 
and not permitted to self-administer your medication. You also say that the hospital personnel controlled and 
managed your care while you were in the emergency room. The Plan denied your request. The Plan says self-
administered drugs are not covered under the medical benefits of your plan. 
 
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 the self-administered drugs 
provided on May 9, 2022, and May 10, 2022.  
 Benefits for the 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99308 and 20610 provided on March 14, 
2022. 
 
You asked the Plan to pay for procedure codes 99308 and 20610. 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. Medicare 
rules also say that if more than one evaluation and management (face-to-face) service is provided on the same 
day to the same patient by the same physician or more than one physician in the same specialty in the same 
group, only one evaluation and management service may be reported. 
 
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 19, 2022. Comparison of the two claims shows these are duplicates. There is 
no evidence presented to support that the billed items/services were provided twice on the same date. 
Additionally, only one E/M service is payable per day. Based on this information, we decided that the 
Medicare rules for procedure codes 99308 and 20610 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 99308 and 20610 provided on March 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive urine drug testing (UDT) for 22 or more drug 
classes (procedure code G0483) provided to the enrollee on April 22, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says ordering a multi-class panel of definitive (confirmation) urine drug tests that are not used in 
clinical management, exceeds the needs of the patient. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided records do not document the required level of detail to verify the denied testing. The 
clinician's rationale for the testing ordered must be documented in the records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for definitive urine drug testing (UDT) for 22 or more drug classes (procedure code G0483) provided to 
the enrollee on April 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intravenous (IV) infusion, hydration (96361) and normal 
saline solution infusion (J7040) provided on May 24, 2022. 
 
You asked the Plan to pay for the IV infusion and normal saline solution infusion. You say that these were 
emergency services that the enrollee needed. You also say that you would like this claim to be reconsidered for 
payment. The Plan denied your request. The Plan says with the provided information it could not be determined 
how the enrollee came to the servicing provider, or whether the services are medically necessary. 
 
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 the intravenous (IV) infusion, 
hydration (96361) and normal saline solution infusion (J7040) provided on May 24, 2022. have been met. 
Medical records were not provided for this case. The record shows that the Plan made multiple attempts to 
obtain records, but they were not provided. Without this information, we cannot determine if the services 
provided were medically necessary. Therefore, we decided that the Plan does not have to pay for the 
intravenous (IV) infusion, hydration (96361) and normal saline solution infusion (J7040) provided on May 24, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a pontic (D6245), and a resin-based composite (D2330) 
provided by Tushar Pradip Bulsara, D.M.D., on May 5, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you are confused as to why you have to 
pay for this. 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 a pontic (D6245), and a resin-based 
composite (D2330) provided by Tushar Pradip Bulsara, D.M.D., on May 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 21, 
2021. 
 
You asked the Plan to pay for procedure code 70450. You say that this should be paid for. 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 July 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary denture (D5110) 
 
You asked the Plan to pre-approve 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 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 February 16, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary denture (D5110)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy on tooth #23 (D3310) provided on April 
13, 2022, and does not have to waive the deductible for a resin-based composite filling on tooth #23 (D2330) 
provided on May 5, 2022. 
 
You asked the Plan to pay for endodontic therapy and to waive the deductible for a filling. You say that you 
disagree with the processing of these dental claims. The Plan denied your request. The Plan says endodontic 
therapy is not covered when received by an out-of-network provider. The Plan also says that you have been 
charged the correct cost sharing amount for a filling. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $100 deductible that applies to basic and major dental services, 
including a filling. Endodontic therapy is a covered service but only when received by an in-network provider. 
 
The filling you asked the Plan to pay for falls within the dental services benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $100 deductible which applies to 
basic and major dental services. This cost sharing is a contractual obligation that had not been met at the time 
the filling was received on May 5, 2022. 
 
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 endodontic therapy from an out-of-network provider on April 13, 2022. 
Though the Plan offers a dental benefit in excess of Medicare coverage, endodontic therapy is 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 endodontic therapy on tooth #23 (D3310) provided on April 13, 2022, and does not have to 
waive the deductible for a resin-based composite filling on tooth #23 (D2330) provided on May 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 19285 and 76942 billed for date of service 
May 9, 2022. 
 
You asked the Plan to pay for procedure codes 19285 and 76942. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says payment for codes 19285 and 
76942 are bundled into payment for code 19083. 
 
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 
19285 and 76942 are column II codes to column I code 19083. 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 codes 19285 and 76942 billed for 
date of service May 9, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on  
February 21, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says the 
member was in hospice on this date of service. The services should be billed to traditional Medicare. 
 
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 subsequent nursing facility care provided on 
February 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 13, 2022, to January 14, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the services provided were medically necessary. The 
Plan denied your request. The Plan says the provider is out-of-network and authorization is required prior to an 
out-of-network visit. 
 
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 an office visit provided on January 13, 2022, to 
January 14, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 20, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 an office visit provided on June 20, 2022, by an 
out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance on May 30, 2022. 
 
You asked the Plan to waive the copayment for ambulance. You say that you want to appeal the amount being 
charged. 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 per one-way trip for ambulance. Covered ambulance services include fixed wing, rotary wing, and 
ground ambulance services to the nearest appropriate facility that can provide care if they are furnished to a 
member whose medical condition is such that other means of transportation could endanger the person's health 
or if authorized by our plan. 
 
You have been asked to pay a $200 copayment for ambulance. This item/service falls within the Ambulance 
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 ambulance on May 30, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the level IV surgical pathology, gross and microscopic 
examination (83305) and special stain including interpretation and report; Group I for microorganisms (e.g., 
acid fast, methenamine silver) (88312) provided March 2, 2021.   
 
You asked the Plan to pay for the laboratory services. You say that please review the attached documentation 
and reprocess the claim for payment. The Plan denied your request. The Plan says the provider is no longer 
credentialed or eligible for Medicare/Medicaid billing of services. The providers license has also been placed 
on permanent inactive status in the states of Missouri and Illinois. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program.  
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the level IV surgical pathology, gross 
and microscopic examination (83305) and special stain including interpretation and report; Group I for 
microorganisms (e.g., acid fast, methenamine silver) (88312) provided March 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional reimbursement for a walker provided on April 28, 
2022. 
 
You asked the Plan to provide additional reimbursement for the walker. You say that you should be reimbursed 
at the in-network rate. The Plan denied your request. The Plan says you have been reimbursed the correct 
amount. 
 
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 out-of-network durable medical equipment (DME) and related supplies.  
 
You have been asked to pay $23.29, which is 50% of the allowed amount for the walker ($46.57 allowed 
amount x 50% coinsurance = $23.29). This item/service falls within the durable medical equipment (DME) and 
related supplies benefit category. You were reimbursed a total of $23.28 ($46.57 allowed amount - $23.29 
coinsurance = $23.28). This means that you have been reimbursed the correct amount based on your contract 
with the Plan. Please note that sales tax and processing fees are not reimbursable expenses. 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 provide additional reimbursement for a walker provided on April 28, 2022.  
 
Please note that neither you nor the Plan are responsible for paying the balance bill. Please contact the 
provider about a refund for any amount you paid above the Medicare allowable amount for this walker. If the 
provider is billing you for charges beyond any applicable cost-sharing amounts, please contact the Plan 
directly.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Tetanus and Diphtheria (TD) vaccine (90714) provided on 
May 20, 2022. 
 
You asked the Plan to pay for a TD vaccine. You say that the services at issue were a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment for immunizations have not been met. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a TD vaccine. The 
Plan follows the same rules.  
 
Records do not show that the enrollee had been injured or directly exposed to any illness related to a TD 
vaccine. Therefore, we decided that the Plan does not have to pay for a Tetanus and Diphtheria (TD) vaccine 
(90714) provided on May 20, 2022.  
 Benefits for a TD vaccine 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for knee braces provided on June 1, 2022. 
 
You asked the Plan to waive the coinsurance for knee braces. You say that you do not feel that you should owe 
the amount you are being asked to pay. 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 durable medical equipment (DME) and related supplies.  
 
You have been asked to pay a 50% coinsurance for knee braces ($658.36  50% = $329.18). This item/service 
falls within the durable medical equipment (DME) and related supplies 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 knee braces provided on June 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services (procedure code 97012) provided to the 
enrollee on April 1, 2022. 
 
You asked the Plan to pay for the services. You say that you wish for the services to be covered. The Plan 
denied your request. The Plan says only manual manipulation of the spine for the treatment of subluxation is 
covered by Medicare. 
 
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 chiropractic services (procedure code 97012) provided to the enrollee on 
April 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on November 30, 2021. 
 
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 procedure codes 20692 and 26735 are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 20692 is application of a multiplane (pins or wires in 
more than 1 plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type). The definition of code 
26735 is open treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, includes 
internal fixation, when performed, each. 
 
We find that CPT codes 20692 and 26735 are not supported in the medical record. Specifically, there is no documentation of the procedures for the billed date of service. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the surgical services rendered on November 30, 2021.