Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care services (99232) provided from 
June 9, 2021, to June 11, 2021. 
 
You asked the Plan to pay for the subsequent hospital care services. You say that the enrollee was not seen in 
your office, but was only seen in the hospital and resides in a nursing facility. The Plan denied your request. 
The Plan says the enrollee confirmed that they did not travel outside of Puerto Rico, and they have not received 
medical services in the United States. 
 
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 subsequent hospital care services 
have been met. Specifically, no documentation was submitted to show that the correct enrollee received the 
provided services. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care 
services (99232) provided from June 9, 2021, to June 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power seat elevation system (E2300) and LED light 
kit (K0108). 
 
You asked the Plan to pre-approve the items. You say that you cannot walk without assistance. The Plan denied 
your request. The Plan says the items are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the power seat elevation system (E2300) and LED light kit 
(K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313), an expandable controller (E2377), 
an attendant control (E2331) and a battery (K0108). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you have ALS and are bound to a 
wheelchair and have no mobility in the legs. You are terminal and need to get to your appointments. Your left 
leg is completely dead. The Plan denied your request. The Plan says although there are three requested power 
options, there is not a medical need to control these power options through the joystick. The Plan also says an 
attendant control cannot be covered in addition to a beneficiary operated joystick. 
 
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 pre-approve wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you have ALS and have impaired ambulation and transfer secondary to decreased leg 
strength. You have adequate upper body strength, per an occupational therapy (OT) evaluation, to manage 
standard switches on a power wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection between wheelchair controller and two or more power 
seating system motors (E2311), a harness (E2313), an expandable controller (E2377), an attendant control 
(E2331) and a battery (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for tocilizumab injections and 
methylprednisolone injections and does not have to waive the deductible for inpatient hospital care provided on 
February 7, 2022, to August 4, 2022. 
 
You asked the Plan to waive the coinsurance for inpatient hospital care, tocilizumab injections and 
methylprednisolone injections. You say that you do not agree with the cost share for the billed services. 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 $450 per 
day, days 1-4, $0 per day, days 5-90; $0 copayment for additional day, after your $1000 plan deductible, for 
inpatient services. You must pay for 20% coinsurance for all other drugs covered under Medicare Part B. 
 
You have been asked to pay $2,465.62 for inpatient hospital care, tocilizumab injections and 
methylprednisolone injections.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
February 7, 2022 Injections $2,275.56 20% $455.11 
February 27, 2022 Inpatient hospital $232.61 $1000 $232.61 
March 7, 2022 Injection $2,275.56 20% $455.11 
May 9, 2022 Injections $2,275.56 20% $455.11 
August 4, 2022 Injections $4,338.40 20% $867.68 
TOTAL:     
 
These items/services falls within the inpatient hospital care and 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 tocilizumab injections and methylprednisolone 
injections and the deductible for inpatient hospital care provided on February 7, 2022, to August 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for retainer crown - porcelain/ceramic (D6245) provided on July 
11, 2022. 
 
You asked the Plan to pay for retainer crown (D6245). You say that your frontal bridge was shattered after an 
accident. You also say that you were unable to bite at all until the procedure was done. The Plan denied your 
request. The Plan says this service is 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 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 retainer 
crown - porcelain/ceramic (D6245) provided on July 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing (83789) provided on September 15, 2022. 
 
You asked the Plan to pay for validity testing. You say that this service is medically necessary and should be 
paid. The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of validity testing have not been met. Specifically, we find that the testing described by the billed code is considered specimen validity testing which is not separately payable. Therefore, we decided that the 
Plan does not have to pay for validity testing (83789) provided on September 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified adjunctive procedure (D9999) provided on 
March 3, 2022. 
 
You asked the Plan to pay for the dental service. You say that the dental services were medically necessary, 
and you provided an x-ray that the Plan requested. The Plan denied your request. The Plan says the denial of 
payment for this service is correct, because the unspecified adjunctive procedure is not covered by the Plan. 
 
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 an 
unspecified adjunctive procedure (D9999) provided on March 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection testing provided on September 
14, 2022, billed with 87150, 87481, 87640, 87653, 87798 and 87799, all reported with modifier -59. 
 
You asked the Plan to pay for the lab testing as billed. You say that this is billed correctly for medically 
necessary testing. The Plan denied your request. The Plan says the codes at issue are not shown to be separate 
and distinct. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
 We asked our coding 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 lab testing as billed. Our reviewer says 
that the billed services are not shown to meet criteria for modifier -59. Our coding reviewer found medical 
coding guidelines and the medical documentation do not support the use of modifier 59. There is a more 
appropriate modifier that can be used. 
 
We looked at this coders review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the lab testing as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the infectious agent detection testing provided on September 14, 2022, billed with 
87150, 87481, 87640, 87653, 87798 and 87799, all reported with modifier -59.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on April 1, 2022, billed with 
codes 87150, 87801, 87798, and 87641. 
 
You asked the Plan to pay for the lab testing as billed. You say that this should be paid. The Plan denied your 
request. The Plan says the modifier used was not appropriate to bypass the coding edit. 
 
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 87150, 87798, 87801, and 87641 is a column II code to column I 
code 87150, 87500, and 87801; however, 87150, 87798, 87801, and 87641 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 lab testing as billed. Our reviewer says that the modifier 
used is not supported to bypass the NCCI edit. Our reviewer found the medical documentation does not support 
the use of modifier 91 to be used with procedure codes. The use of this modifier is to signify that there was a 
Repeat test done and this was not documented. 
 
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 lab testing as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory testing provided on April 1, 2022, billed with codes 87150, 87801, 
87798, and 87641.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the palliative treatment (D9110) provided by on October 25, 
2022. 
 
You asked the Plan to pay for the dental service. You say that you had a cavity that was filled, and the service 
had nothing to do with a crown. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because the palliative treatment is not covered by the Plan. 
 
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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
palliative treatment (D9110) provided by on October 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the extraction (D7210) for tooth #15 and to pay for the 
therapeutic drugs (D9610) provided by an out-of-network provider on August 31, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were told the dental procedures would 
be covered at 50%. The Plan denied your request. The Plan says you are responsible for any charged amount 
above the Plan's cost-sharing amount when your services are received from an out-of-network provider. Also, 
the denial of payment for the therapeutic drugs is correct, because it is not covered by the Plan. 
 
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. 
 
You have been asked to pay the difference between the out-of-network provider's charges and the Plan's 
payment. The total allowed amount for the extraction was $184 with a coinsurance of $92 ($184 total amount x 
50% coinsurance). The total amount the provider billed was $374 with a difference between the allowed 
amount of $190 ($374 billed - $184 allowed amount). The total liability was $282 ($92 coinsurance + $190 
difference amount). This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. The therapeutic drugs are not covered under the Plan's dental benefit. Therefore, we decided that the Plan 
does not have to pay more for the extraction (D7210) for tooth #15 and to pay for the therapeutic drugs 
(D9610) provided by an out-of-network provider on August 31, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the urine PCR (polymerase chain reaction) panel billed for date of 
service November 3, 2022, with procedure codes 87150, 87798, 87481, 87640, and 87653 
 
You asked the Plan to pay for the urine PCR panel. You say that these services were necessary and were 
reported appropriately. The Plan denied your request. The Plan says that these services cannot be billed by 
stacking codes and must be reported with a single panel code. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not cite the rule used to deny these services. We were 
unable to find this rule in a document, determination or article which applies to the state where these services 
were performed. The Plan has failed to properly substantiate their denial in this case and has provided no other 
reason for denial of these services. Therefore, we decided that the Plan has to pay for the urine PCR 
(polymerase chain reaction) panel billed for date of service November 3, 2022, with procedure codes 87150, 
87798, 87481, 87640, and 87653  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lenses (V2781) purchased on July 12, 2022. 
 
You asked the Plan to pay for the progressive lenses. You say that you called and got pre-approval before 
proceeding. The Plan denied your request. The Plan says this service is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for the progressive lenses (V2781) purchased on July 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the excision or destruction (eg, laser), intranasal lesion; 
internal approach, (Clarifix) (30117). 
 
You asked the Plan to pre-approve the Clarifix procedure. You say that you need this to be approved and 
reconsidered since this is hindering your life. The Plan denied your request. The Plan says The Clarifix 
procedure is considered investigational and still being studied as a treatment option for your nasal congestion. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Clarifix procedure have not been met. Therefore, we decided that the Plan does not have to pre-
approve the excision or destruction (eg, laser), intranasal lesion; internal approach, (Clarifix) (30117).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
September 26, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service September 26, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service December 2, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that multiple exams were done on this date of 
service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for code 
93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service December 2, 
2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (87150, 87798, 87481, 87640, and 87653) provided 
on November 2, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says that these services are considered a test 
panel and should be billed with a single unit of service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan does not cite the rule used to deny these services. We were 
unable to locate this rule in an article or determination which applies to the state where these services were 
performed. The Plan has failed to properly support their denial in this case and has provided no other reason for 
why these services should be denied. Therefore, we decided that the Plan has to pay for laboratory services 
(87150, 87798, 87481, 87640, and 87653) provided on November 2, 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 procedure codes 95972 and L8680 billed for date of service September 14, 2022.

You asked the Plan to pay for procedure codes 95972 and L8680. You say that these were separate services. The Plan denied your request. The Plan says payment for code 95972 is bundled into payment for code 63650. In addition, the Plan says that code L8680 is not separately payable.

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 95972 is a column II code to column I code 63650. 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 for payment of code 95972. In addition, Medicare rules state that code L8680 is not separately payable when billed with code 63650. Therefore, we decided that the Plan does not have to pay for procedure code 95972 billed for date of service September 14, 2022.