Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core build-up (D2950), a retainer crown (D6751), and 
a pontic (D6241), provided by a participating provider. 
 
You asked the Plan to pre-approve a core build-up, a retainer crown, and a pontic. You say that you would like 
the Plan to pay for this. The Plan denied your request. The Plan says this claim has been processed correctly. 
 
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 core build-
up when the services are medically necessary and reasonable. The Plan does not include D6751 or D6241. 
 
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 a core build-up, a retainer crown, and a 
pontic. Our reviewer says that these services are not medically necessary. Our physician reviewer found the 
criteria has not been met for D2950. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a core build-up have not been met. A retainer crown and a pontic are not covered benefits. Therefore, we decided that the Plan does not have to pre-approve a core build-up (D2950), a 
retainer crown (D6751), and a pontic (D6241), provided by a participating provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to provide reimbursement for the COVID-19 polymerase chain reaction (PCR) 
testing provided on December 20, 2021. 
 
You asked the Plan to provide reimbursement for the COVID PCR testing. You say that your doctor told you 
that you were correct to seek this test since his office does not provide this service. You feel it should be 
covered because you had symptoms and needed to know if you had COVID-19. The Plan denied your request. 
The Plan says that at-home COVID testing is not covered by your Plan. 
 
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. We find that the Plan's review for an over-the-counter (OTC) COVID-19 test kit 
is not appropriate. Review of the provider at issue's website shows that they offer standard laboratory PCR 
testing for the price of $149.50, which is what you paid and are requesting reimbursement for. There is no 
evidence that an OTC COVID test was purchased. The Plan did not attempt to obtain medical records, and you 
report that you had COVID symptoms and went to this provider as your primary care doctor does not provide 
COVID testing or write prescriptions for such testing. We find that the Plan's denial rationale is not 
substantiated. Therefore, we decided that the Plan has to provide reimbursement for the COVID-19 polymerase 
chain reaction (PCR) testing provided on December 20, 2021.  
 
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 X-rays of the spine (72020), jaw (70100), and swallowing 
function (74230), with initial hospital care (99222) provided on January 4, 2022. 
 
You asked the Plan to pay for X-rays of the spine, jaw, and swallowing function, with initial hospital care. You 
say that the services at issue were billed and coded correctly. The Plan denied your request. The Plan says rules 
for payment have not been met. 
 
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 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 X-rays of the spine, jaw, and swallowing function, with 
initial hospital care. Our reviewer says that the CPT codes at issue do not meet criteria for payment. Our 
reviewer found that the documentation supports the studies represented by the reported CPT codes were 
performed at a nursing home (via mobile van/portable X-ray) which are denied as an excluded place of service. 
In addition, the provider is billing the technical component modifier and the professional component modifier on the same claim. Both the modifier 26 (for professional component) and modifier TC (for technical 
component) cannot be paid when billed by the same provider with the same Tax ID number. The records do not 
support that the codes at issue were properly reported, with the appropriate modifiers, on the correct claims. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of X-rays of the spine, jaw, and swallowing function, with initial hospital care 
have not been met. Therefore, we decided that the Plan does not have to pay for X-rays of the spine (72020), 
jaw (70100), and swallowing function (74230), with initial hospital care (99222) provided on January 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel provided on December 9, 2021. 
 
You asked the Plan to pay for the general health panel. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel 
provided on December 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drainage of tendon sheath (26020) provided on November 
24, 2021. 
 
You asked the Plan to pay for drainage of tendon sheath (26020). You say that there are no bundling issues 
when billing this code with 26135 and 26145. You say that the doctor performed the procedure separate from 
the surgical procedure and the claim should be reprocessed allowing payment for CPT code 26020. The Plan 
denied your request. The Plan says this procedure is considered inclusive to CPT code 26145. 
 
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 26020 is drainage of tendon sheath, digit and/or palm, 
each. 
 
  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 drainage of tendon sheath (26020). Our reviewer says that 
the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found the 
operative report describes a tenosynovectomy. In this case, drainage of the tendon sheath would be inclusive 
and modifier -59 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of drainage of tendon sheath (26020) have not been met. Therefore, we decided 
that the Plan does not have to pay for drainage of tendon sheath (26020) provided on November 24, 2021.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the diagnostic services from August 10, 2021 through August 13, 2021. 
 
You asked the Plan to pay for the diagnostic services provided from August 10, 2021 through August 13, 2021. 
You say that the services provided were medically necessary. The Plan denied your request. The Plan says that 
an invalid Place of Service code was billed. 
 
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. The Plan says the services were denied due to an invalid Place of Service code 
being billed. The Plan did not submit any documentation confirming what services were billed or what Place of 
Service code was billed. This means we cannot confirm the claim was billed incorrectly. It is the burden of the 
Health Plan to substantiate their denial with evidence. In this case, the denial has not been substantiated so we 
must find in your favor. Therefore, we decided that the Plan has to pay for the diagnostic services from August 
10, 2021 through August 13, 2021.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on August 11, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that the emergency was pretty much over once 
the ambulance arrived. The Plan denied your request. The Plan says since there was no transport provided on 
the date of service, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 11, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on August 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on February 22, 2022. 
 
You asked the Plan to pay for physical therapy services. The Plan denied your request. The Plan says prior 
authorization was not obtained by the provider or facility. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physical therapy services provided on February 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from 
March 22, 2021, through March 23, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was medically 
necessary. The Plan denied your request. The Plan says the inpatient admission was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that you were evaluated in the Emergency Department (ED) on March 21, 2021 for dizziness. The neurologic examination was non focal and the MRI showed a possible pituitary tumor. The 
neurology consultation in the ED recommended that you be admitted "at least for observation" given the 
severity of your symptoms. You were admitted on March 22, 2021 and discharged on the following day. The 
record does not show that at the time of inpatient admission the admitting physician reasonably expected that 
your necessary hospital care (including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from March 22, 2021, through 
March 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for shingles vaccine provided on February 17, 2022. 
 
You asked the Plan to pay for shingles vaccine. You say that the vaccine should be covered since the nurse 
offered you it. The Plan denied your request. The Plan says the vaccine is not covered. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide shingles vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to shingles vaccine. 
Therefore, we decided that the Plan does not have to pay for shingles vaccine provided on February 17, 2022. 
Benefits for shingles 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrocardiographic services (93246, 93248) provided on 
November 22, 2021. 
 
You asked the Plan to pay for electrocardiographic services. You say that you have provided medical records to 
support the services at issue. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 93246 is "External electrocardiographic recording for 
more than 7 days up to 15 days by continuous rhythm recording and storage; recording (includes connection 
and initial recording)"; and of code 93248 is "External electrocardiographic recording for more than 7 days up 
to 15 days by continuous rhythm recording and storage; review and interpretation." 
 We find that CPT codes 93246 and 93248 are not supported in the case record. Specifically, the services at 
issue have a 15-day duration. The Plan has documented that the same codes were previously billed fewer than 
15 days prior to the date of service at issue in this case. Based on this information, we decided that Medicare 
rules for coverage of electrocardiographic services have not been met. Therefore, we decided that the Plan does 
not have to pay for electrocardiographic services (93246, 93248) provided on November 22, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
January 4, 2022 to February 2, 2022. 
 
You asked the Plan to pay for home health 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. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, this claim 
has been billed for a 30-day episode of care; however, the through date of February 2, 2022 is billed as the 30th 
day from the from date billed of January 4, 2022. This means this is incorrect and should be the 29th day billed. 
Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee 
from January 4, 2022 to February 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the durable medical equipment (DME) 
provided on February 11, 2022. 
 
You asked the Plan to waive the coinsurance for the DME. You say that you do not use the brace and would 
like to return it. The Plan denied your request. The Plan says the proper coinsurance was applied for the service 
rendered. 
 
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 In-network Medicare-covered equipment and supplies. The total amount allowed for the DME 
was $240.08 with a coinsurance amount of $48.02 ($240.08 total amount x 20% coinsurance). 
 
  You have been asked to pay $48.02 coinsurance for the DME. The DME 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 the durable medical equipment (DME) provided on February 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from November 
6, 2021 to November 17, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that when you got out of the 
hospital you wanted to go home. You say the physicians were not ready for you to be discharged because they 
wanted you to go to rehab. The Plan denied your request. The Plan says you have been charged the correct 
copayment 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 $325 
copayment per admission, per day for days 1-5.  
 
 
 
 
 You have been asked to pay a total of $1,625, which is a $325 copayment per day for days 1-5 for an inpatient 
hospital stay ($325 x 5 days = $1,625). The inpatient hospital stay falls within the Inpatient hospital 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 an inpatient hospital stay from 
November 6, 2021 to November 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for bone and joint imaging on February 17, 
2022. 
 
You asked the Plan to waive the coinsurance for bone and joint imaging. You say that you don't feel like this is 
your responsibility and that you thought the provider was in-network. The Plan denied your request. The Plan 
says the cost share applied 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 50% 
coinsurance for bone and joint imaging.  
 
You have been asked to pay 50% coinsurance for bone and joint imaging. bone and joint imaging falls within 
the bone and joint imaging 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 bone and 
joint imaging on February 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the iron studies provided on December 15, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
billed with the appropriate diagnosis codes. 
 
The Plan must follow Medicare rules. Medicare rules say that only certain diagnosis codes are covered for 
serum iron studies.  
 
We looked at the file and Medicare rules. The lab services were billed with diagnosis codes G40.89, G93.40, 
F10.231, and I10. Per NCD 190.18, these codes are not listed as covered diagnosis codes for these services in 
question. Based on this information, we decided that Medicare rules for coverage of the services have not been 
met. Therefore, we decided that the Plan does not have to pay for the iron studies provided on December 15, 
2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intravenous infusion coded 96361 and the therapeutic, 
prophylactic, or diagnostic injection services coded 96374 provided on October 30, 2021. 
 
You asked the Plan to pay for the intravenous infusion and the therapeutic, prophylactic, or diagnostic injection 
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 code 96361 and 96374 is not supported in the medical record. Specifically, code 96374 is not 
reportable when provided in a facility setting such as an emergency department. This means this service is not a 
covered benefit. The add on code, code 96361 is therefore, also not payable due to the primary procedure being 
denied. Based on this information, we decided that Medicare rules for coverage of the intravenous infusion and the therapeutic, prophylactic, or diagnostic injection services have not been met. Therefore, we decided that the 
Plan does not have to pay for the intravenous infusion coded 96361 and the therapeutic, prophylactic, or 
diagnostic injection services coded 96374 provided on October 30, 2021.