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

 
We decided that the Plan does not have to pay for the intensity modulated radiation treatment delivery (77386) 
provided on May 2, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the radiation therapy. You say that authorization was obtained. You say that that 
the service was medically necessary. The Plan denied your request. The Plan says prior authorization was not 
obtained. 
 
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 in this case is not a network provider with the Plan. 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 intensity modulated radiation treatment delivery (77386) 
provided on May 2, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81265) provided April 1, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim was not billed with a valid diagnosis code. 
 
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 find that CPT code 81265 is not supported in the medical record. Specifically, D75.81 is a manifestation 
code and cannot be listed as a primary diagnosis code. Based on this information, we decided that Medicare 
rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to 
pay for lab services (81265) provided April 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for immunology on March 14, 2022. 
 
You asked the Plan to waive the coinsurance for immunology. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
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 20% 
coinsurance of the cost for Medicare Part B drugs. The provider billed in the amount of $4,456.44 and the 
allowed amount is $1,173.36. $1,173.36 x 20% = $234.67. Therefore, results in the total cost sharing amount of 
$234.67. 
 
You have been asked to pay a 20% coinsurance for immunology. Immunology 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 immunology on 
March 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 75716 and 99153 billed on December 23, 
2021. 
 
You asked the Plan to pay for procedure codes 75716 and 99153. You say that the enrollee had multiple exams 
on this date of service and the reports support the level of service. You say that the claim should be 
reconsidered for processing. The Plan denied your request. The Plan says procedure code 75716 is considered 
inclusive to procedure code 37227. The Plan also says that the place of service is inappropriate for procedure 
code 99153. 
 
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 75716 is a column II code to column I code 37227; however, 75716 
was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 75716 and 99153. Our reviewer says that 
the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found the 
procedure report describes an intervention performed on unilateral extremity. In this case, the bilateral 
angiography is inclusive to the intervention procedure. Therefore, procedure code 75716 cannot be verified. In 
addition, procedure code 99153 cannot be paid separately. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 75716 and 99153 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 75716 and 99153 billed on December 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0239U billed for date of service March 23, 
2022. 
 
You asked the Plan to pay for procedure code 0239U. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 0239U is bundled into payment for code 0037U. 
 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 0239U 
is a column II code to column I code 0037U. 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 0239U billed for date of service March 23, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a therapy visit provided on April 27, 2022. 
 
You asked the Plan to waive the copayment for a therapy visit. You say that you never had a copayment like 
this before and cannot afford it. The Plan denied your request. The Plan says you were charged this cost sharing 
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 $25 
copayment for individual, or group therapy visit for Medicare-covered outpatient mental health services.  
 
You have been asked to pay a $25 copayment for a therapy visit. A therapy visit falls within the Outpatient 
Mental Health 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 a therapy visit 
provided on April 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy (D3320) and additional intraoral 
periapical x-ray (D0230) provided on January 4, 2022. 
 
You asked the Plan to pay for the endodontic therapy and additional intraoral periapical x-ray. You say that you 
would like these services to be paid by the Plan, because you were led to believe you had coverage for the work 
that was performed. The Plan denied your request. The Plan says endodontic therapy is not a covered expense 
under your dental plan. The Plan also says that your intraoral x-rays benefit has been satisfied and the 
frequency limitation has been exceeded. 
 
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, endodontic therapy (D3320) is not 
among those covered under this benefit. The contract clearly states that intraoral x-rays are limited to one 
procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray (D0220) 
on January 4, 2022, and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan 
does not have to pay for the endodontic therapy (D3320) and additional intraoral periapical x-ray (D0230) 
provided on January 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that these items were authorized for the 
enrollee in the past. You say that the requested garments are medically necessary for the enrollee's lymphedema 
treatments. The Plan denied your request. The Plan says the requested item is not covered under your contract 
or through Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair, group 4 standard, single power 
option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0877). 
 
You asked the Plan to pre-approve a power wheelchair. You say that you are requesting an electric scooter to 
help the enrollee with mobility when she is out of home. You report that it is difficult to push her wheelchair. 
The Plan denied your request. The Plan says the enrollees home provides adequate access between rooms, 
maneuvering space, and surfaces for the operation of the power wheelchair that is provided, and it appears the 
use will be mostly outside the home and not to assist with MRADLs. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power wheelchair, group 4 standard, single power option, sling/solid seat/back, patient 
weight capacity up to and including 300 pounds (K0877).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for infusion drugs provided on May 17, 2022. 
 
You asked the Plan to waive the coinsurance for the infusion drugs. You say that you do not know why you are 
being charged for this now. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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 20% 
coinsurance for Part B drugs obtained in a provider's office or outpatient setting.  
 
You have been asked to pay $39.58, which is 20% of the allowed amount for the infusion drugs ($197.91 
allowed amount x 20% coinsurance = $39.58). The infusion drugs fall 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 infusion drugs provided on May 
17, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ambulance services and an emergency 
room (ER) visit provided on April 13, 2022. 
 
You asked the Plan to waive the copayments for the ambulance services and ER visit. You say that you were 
forced to take the ambulance to get home. The Plan denied your request. The Plan says you were charged this 
cost sharing 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 $150 
copayment for each one-way ambulance service. 
 
Your contract with the Plan also clearly says that you must pay a $90 copayment for each emergency room 
visit. You have been asked to pay a $150 copayment for the ambulance services. The ambulance services fall within 
the Ambulance Services benefit category. You have also been asked to pay a $90 copayment for the ER visit. 
The ER visit falls within the Emergency Care benefit category. The total for all services is $240. 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 copayments for ambulance services and an emergency room (ER) visit provided on 
April 13, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services on April 13, 
2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost sharing you are being charged is 
correct. 
 
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 $120 
copayment for emergency room. Emergency care refers to services that are furnished by a provider qualified to 
furnish emergency services and needed to evaluate or stabilize an emergency medical condition and a medical 
emergency is when you, or any other prudent layperson with an average knowledge of health and medicine, 
believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of 
a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical 
condition that is quickly getting worse. 
 
 You have been asked to pay a $120 copayment for emergency room services. Emergency room services fall 
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 emergency 
room services on April 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 26, 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 appeal the denial of the 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 April 26, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided May 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that this service was necessary. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 17, 2022. Therefore, 
we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided May 19, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
November 25, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you feel the service 
should be covered. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
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 $300 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $300 copayment for the ambulance transportation. The ambulance transportation 
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 transportation provided on November 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reconsider the overpayment recovery for a crown on tooth #22 and 
27 (D2750) provided on July 1, 2021. 
 
You asked the Plan to reconsider the overpayment recovery for crowns. You say that you do not believe you 
should have to pay back the money. The Plan denied your request. The Plan says an overpayment was made for 
the crowns you received. 
 
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 this benefit includes coverage up to $1,200 for preventive and comprehensive dental services. 
 
The record shows you should have only been reimbursement $470 for the crowns received on July 1, 2021. 
Crowns fall within the Dental Services benefit category. This means that you have been correctly asked to 
repay the overpayment of $464.25. 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 reconsider the overpayment recovery 
for a crown on tooth #22 and 27 (D2750) provided on July 1, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you require twenty-four hour assistance to ensure 
complete recovery. You say that it is not safe to discharge home and your surgeon recommends SNF. The Plan 
denied your request. The Plan says the medical services/item you requested does not meet the clinical criteria 
for SNF admission. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you were at a stand-by assist to independent level with functional mobility including 
gait to 400 feet. You required varying assist with activities of daily living skills. You do not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You 
do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. Our reviewer also found you do not require daily skilled nursing and/or skilled therapy 
on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the periodontal maintenance (D4910) and 
the localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per 
tooth (D4381) provided on May 20, 2022. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not covered under your 
contractual policy. 
 
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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to issue reimbursement for 
the periodontal maintenance (D4910) and the localized delivery of antimicrobial agents via a controlled release 
vehicle into diseased crevicular tissue, per tooth (D4381) provided on May 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deep sedation/general anesthesia (D9222), additional deep 
sedation/general anesthesia (D9223), and a surgical extraction of tooth# 18, 20, 22, 23, 24, 25, 26, 27, and 29 
(D7210) provided on April 28, 2022. 
 
You asked the Plan to pay for the dental 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 pay for deep 
sedation/general anesthesia (D9222), additional deep sedation/general anesthesia (D9223), and a surgical 
extraction of tooth# 18, 20, 22, 23, 24, 25, 26, 27, and 29 (D7210) provided on April 28, 2022.