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

 
We decided that the Plan does not have to pay for additional moderate sedation services (99153) provided on 
November 11, 2021. 
 
You asked the Plan to pay for additional moderate sedation services. You say that you have provided records to 
support the service at issue. The Plan denied your request. The Plan says rules for payment have not been met. 
 
Medicare rules say that for services paid via the PFS, each code is assigned both physician work and PE RVUs. 
PE RVUs are often reduced for physician services rendered in the facility setting. Since payment for many PE 
expenses, such as staff wages and supplies, is included in Medicare payment to the facility, payment associated 
with those resource costs is not made under the PFS. The rules also state specifically that nursing services and 
supplies provided in an ASC are included in the ASC payment rate for the procedure. 
 
We looked at the file and Medicare rules. The code 99153 has a Pro/Tech flag of 3 in the PFS. This indicator 
identifies stand- alone codes that describe the technical component (i.e., staff and equipment costs) of selected 
diagnostic tests for which there is an associated code that describes the professional component of the 
diagnostic test only. The total RVUs for technical component only codes include values for practice expense 
and malpractice expense only.  
 
Because code 99153 does not include physician work but reimburses PE RVUs, the services described by this 
code are nursing/technician services and supplies. Payment for this is made to the ASC facility and cannot be 
paid to the physician. As such, payment to the physician for code 99153 in the ASC setting is not allowed. 
Based on this information, the Medicare rules for payment of code 99153 have not been met. Therefore, we 
decided that the Plan does not have to pay for additional moderate sedation services (99153) provided on 
November 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the 20% coinsurance charged for injections to the knee
provided on August 22, 2021.
You asked the Plan to waive this coinsurance. You say that you do not believe this coinsurance is correct and
this is a financial hardship. The Plan denied your request. The Plan says this coinsurance was charged based on
the drug and the service provided and the Plan contract agreement. Maximus overturned the Plans denial for
missing information in the case file. The Plan requested a reopen and provided the required information.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. Your contract with the Plan clearly says that you must pay 20% coinsurance for each
Medicare Part B drug. Injections to knee provided by a physician qualify for this coinsurance. 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 20% coinsurance charged for injections to the knee provided on August 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 1 unit of spinal surgery services coded 63048-59 and 
microsurgical techniques coded 69990 provided on November 3, 2021. 
 You asked the Plan to pay for the surgery services as billed. You say that you would like these codes 
reprocessed and approved for payment. The Plan denied your request. The Plan says the documentation does 
not support payment for these services as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Regarding an additional unit of CPT code 63048-59, the documentation submitted was reviewed, and the 
criteria for coverage have not been met. In this case, the operative report describes laminectomy performed on 
L4, L5 - S1, which supports two segments treated. Provider was reimbursed for initial segment, and second 
segment (63047, 1 unit of 63048-59). Any additional segments are not supported by the operative report, and 
therefore cannot be verified. 
 
In this case, we have confirmed that code 69990 is a column II code to column I code 63047 with a modifier 
indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for 1 unit of spinal surgery 
services coded 63048-59 and microsurgical techniques coded 69990 provided on November 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81206, 81292, and 81301 
provided on August 20, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
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 codes 81206, 81292, and 81301 are not supported in the medical record. Specifically, when a 
laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be considered part 
of the same panel. A panel constitutes a single procedural service, so one code must be billed for the panel. 
Review of the file does not support that only one code was billed for the panel. This means these codes are not 
payable as billed. Based on this information, we decided that Medicare rules for coverage of the laboratory 
services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
coded 81206, 81292, and 81301 provided on August 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the epidurogram provided during a spinal injection on 
October 27, 2021, billed with code 72275. 
 
You asked the Plan to pay for the services as billed. You say that this should be paid as billed. The Plan denied 
your request. The Plan says the modifier is not appropriate to bypass the coding edits between these codes. 
 
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 72275 is a column II code to column I code 64483; however, 72275 
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 the services as billed. Our reviewer says that the 
documentation does not support separate payment, as the modifier is not shown to be clinically appropriate to 
bypass the PTP edit. Our reviewer found the procedure report describes a transforaminal epidural steroid 
injection was performed under fluoroscopic guidance at L4-L5. In this case, (per CPT 64483 code description 
"with imaging guidance"), radiology services are included in the primary procedure and would not be reported 
separately. Modifier -59 cannot be verified and is inappropriate to report for service provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the epidurogram provided during a spinal injection on October 27, 2021, billed with 
code 72275.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on October 
27, 2021. 
 
You asked the Plan to pay for the special anesthesia service (99100). You say that the medical records support 
the CPT codes billed. The Plan denied your request. The Plan says procedure code 00918 will be overturned, 
and procedure code 99100 remains denied as bundled services are not eligible for separate payment. 
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the special anesthesia service (99100) have not been met. Therefore, we decided that the Plan does not have 
to pay for the special anesthesia service (99100) provided on October 27, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99285, G0378, 93000, 70450, 74176, 
71250, 85025, 80053, 83880, 81003, 82150, 82977, 87428, 87088, 82553, 84484, 83874, 93000-76, J0295, 
J2550, 96365, 96361, and 96367 provided on December 27, 2021. 
 
You asked the Plan to pay for these services. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, CPT codes 93000 and 93000-76 have a status indicator 
of M and the claim submitted denied for OCE 72 per Medicare payment guidelines. The Plan states they will 
accept a corrected claim for payment reconsideration for all claim lines. Therefore, we decided that the Plan 
does not have to pay for procedure codes 99285, G0378, 93000, 70450, 74176, 71250, 85025, 80053, 83880, 
81003, 82150, 82977, 87428, 87088, 82553, 84484, 83874, 93000-76, J0295, J2550, 96365, 96361, and 96367 
provided on December 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
March 10, 2022. 
 
You asked the Plan to pay for the dental service. You say that you told the dentist to check your history to see 
what services have been done. You say that they did not. You say that there were expensive x-rays that were 
done. You also say that you did not approve for these to be done. The Plan denied your request. The Plan says 
the frequency limit 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and the service is listed as covered, 
there are frequency limits that apply. The record shows that the Plan paid for a comprehensive oral evaluation 
that you received on May 3, 2021. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150) provided on March 10, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the topical application of fluoride varnish (D1206) provided March 4, 2022. 
 
You asked the Plan to pay for the fluoride varnish. You say that information about your dental policy is not 
clear. The Plan denied your request. The Plan says that this service is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers fluoride 
treatments once every year. 
 
We looked at the file and Medicare rules. In this case the Evidence of Coverage does not specify that only 
specific fluoride treatments are covered. There is no evidence that the Plan has already covered a fluoride 
treatment in 2022. Based on this information, we decided that the Plan's rules for coverage of the fluoride 
varnish have been met. Therefore, we decided that the Plan has to pay for the topical application of fluoride 
varnish (D1206) provided March 4, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical trays, surgical supplies, and Propofol 
(anesthetic) provided during a procedure on September 7, 2021, billed with codes A4550, A4649, and J2704. 
 You asked the Plan to pay for the supplies and drugs. You say that this claim should be paid. The Plan denied 
your request. The Plan says the surgical services were paid according to the ASC rate; however, no separate 
payment can be made for codes A4550, A4649, and J2704. 
 
The Plan must follow Medicare rules. Medicare rules say that ASC services for which payment is included in 
the ASC payment for a covered surgical procedure include nursing, technician, and related services; and, 
Materials, including supplies and equipment for the administration and monitoring of anesthesia. 
 
We looked at the file and Medicare rules. The codes at issue are supplies directly related to the surgical 
procedure. These are covered, but payment is included in the payment for the surgical procedure itself. Based 
on this information, we decided that Medicare rules for coverage of the supplies and drugs have not been met. 
Therefore, we decided that the Plan does not have to pay for the surgical trays, surgical supplies, and Propofol 
(anesthetic) provided during a procedure on September 7, 2021, billed with codes A4550, A4649, and J2704.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service October 22, 2021. 
 You asked the Plan to pay for procedure code 93042. You say that these services were coded and billed 
appropriately. The Plan denied your request. The Plan says payment for code 93042 is bundled into payment 
for code 93308. 
 
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 93042 
is a column II code to column I code 93308. 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 93042 billed for date of service October 22, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from January 24, 2022, 
to February 21, 2022. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee 
no longer required daily skilled care from either a nurse or a therapist. 
 
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 pay for the skilled nursing services provided from 
January 24, 2022, to February 21, 2022. Our reviewer says that the enrollee did not meet the Medicare criteria 
for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required 
the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily 
skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional 
therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 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 the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from January 24, 2022, to February 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic x-ray (D0330) provided on February 18, 2022. 
 
You asked the Plan to pay for an x-ray. You say that you disagree with the denial of dental services. The Plan 
denied your request. The Plan says panoramic x-rays (D0330) are not covered by your supplemental dental 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
panoramic x-ray (D0330) provided on February 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tooth extraction (D7210) provided by an oral surgeon. 
 
You asked the Plan to pre-approve a tooth extraction. You say that you are in severe pain, and you were 
referred to the oral surgeon by your dentist. The Plan denied your request. The Plan says dental services must 
be performed by a participating general dentist. 
 
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 a tooth 
extraction when the services are performed by a participating general dentist.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a tooth extraction have not been met. Specifically, dental services must be performed by a 
participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a tooth 
extraction (D7210) provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for personal protective equipment (PPE) provided on February 
16, 2021. 
 
You asked the Plan to pay for PPE. You say that the provider was listed as in-network in the Plan's benefit 
booklet. The Plan denied your request. The Plan says PPE is not covered by your supplemental dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for personal 
protective equipment (PPE) provided on February 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided 
February 16, 2022. 
 
You asked the Plan to pay for the fluoride varnish. You say that you were not aware that this service is not 
covered. The Plan denied your request. The Plan says this service is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
topical application of fluoride varnish (D1206) provided February 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7210) by an out-of-network provider on 
March 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were unaware that the rules changed on 
out-of-network providers. The Plan denied your request. The Plan says the dental services were received from 
an out-of-network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for an extraction (D7210) by an out-of-network provider on March 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mandibular partial denture (D5214) provided on January 7, 2022. 
 
You asked the Plan to pay for the dentures. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says a mandibular partial denture (D5214) is not covered by your dental 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 a 
mandibular partial denture (D5214) provided on January 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 12, 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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results 
and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on April 12, 2021.