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

 
We decided that the Plan does not have to pay for medical services provided on November 14, 2022, billed 
with procedure codes 70450, 74018, and 74176. 
 
You asked the Plan to pay for the medical services. You say that the member had multiple exams done on this 
date of service. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on December 06, 2022. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the medical services have not been met. 
Therefore, we decided that the Plan does not have to pay for medical services provided on November 14, 2022, 
billed with procedure codes 70450, 74018, and 74176.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prophylaxis - adult (D1110) provided on December 7, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you believe you should only have to pay $10 for 
your dental appointment but received a bill for $75. The Plan denied your request. The Plan says your benefit 
for the prophylaxis - adult 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 prophylaxis - adult was exhausted on date of service February 8, 2022, and August 
23, 2022. Therefore, we decided that the Plan does not have to pay for a prophylaxis - adult (D1110) provided 
on December 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for items billed with codes A4927-GY and A4520-GY for date 
of service November 28, 2022. 
 
You asked the Plan to pay for items billed with codes A4927-GY and A4520-GY. You say that you did not 
provide a specific argument with your appeal request. The Plan denied your request. The Plan says claims with 
the GY modifier are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that the GY modifier must be used when physicians, 
practitioners, or suppliers want to indicate that the item or service is statutorily non-covered or is not a 
Medicare benefit. You billed the items in dispute with the GY modifier, so these items are not covered by 
Medicare. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of items billed with codes A4927-GY and A4520-GY have not been met. Therefore, we decided that the Plan does not have to pay for items billed with codes A4927-GY and A4520-GY for date of service 
November 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
December 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had a broken tooth, and this exam was 
medically 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 November 17, 2022. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on December 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on October 22, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that someone 
else called the ambulance without your consent. You also say that you did not want the transport because you 
thought you were okay and did not want to leave your car a distance away from your home and the emergency 
room. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
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 October 22, 2022. 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 with no 
transport provided on October 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for labial veneer (resin laminate) - direct (D2960) provided on 
January 21, 2022. 
 
You asked the Plan to pay for dental services. You say that you would like your insurance to help cover the 
billed amount, because you are unable to afford the cost of the service received. The Plan denied your request. 
The Plan says this service is not covered under your 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. Labial veneer (resin laminate) 
- direct (D2960) is not covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D2960 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for labial veneer 
(resin laminate) - direct (D2960) provided on January 21, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing and remote monitoring provided on January 25, 2022. 
 
You asked the Plan to pay for testing and remote monitoring. You say that this was medically necessary and 
should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for testing and remote 
monitoring provided on January 25, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 30, 2022, to 
September 28, 2022. 
 You asked the Plan to pay for the home health services as billed. 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 follows Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and the rules. The claim was billed with a type of bill 322. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the home health services provided from August 30, 2022, to September 
28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 6, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), bitewings (D0274), 
a cleaning (D1110), and a resin-based composite (D2331) for tooth #6 provided by an out-of-network provider 
on December 1, 2022, and December 8, 2022. 
 
You asked the Plan to pay more for the dental services. You say that all the preventative care should be 100% 
covered but none of it was covered by the Plan. The Plan denied your request. The Plan says you are 
responsible for any charged amount above the Plans cost-sharing amount when your services are received 
from an out-of-network provider. Also, the proper cost share was applied. 
 
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 total allowed amount for the oral evaluation was $35 and the total billed amount was $94 leaving the 
difference amount of $59 ($94 billed - $35 amount). The total amount for the bitewings was $42 and the total 
billed was $107 leaving the difference amount of $65 ($107 billed - $42 allowed). The total allowed amount for 
the cleaning was $69 and the total billed amount was $155 leaving the difference amount of $86 ($155 billed - 
$69 allowed). The total enrollee responsibility for the dental services on December 1, 2022, was $210 ($59 
difference + $65 difference + $86 difference). The total allowed amount for the resin-based composite was 
$134 and the total billed amount was $327 leaving the difference amount of $193 ($327 billed - $134 allowed). 
After the $100 deductible was charged the allowed amount left was $34 ($134 allowed - $100 deductible). The 
total coinsurance amount was $17 ($34 total left amount x 50% coinsurance). The total enrollee responsibility 
was $310 ($193 difference + $100 deductible + $17 coinsurance). You have been asked to pay the difference 
between the out-of-network providers charges and the Plans payment along with a deductible and 50% 
coinsurance. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), 
bitewings (D0274), a cleaning (D1110), and a resin-based composite (D2331) for tooth #6 provided by an out-
of-network provider on December 1, 2022, and December 8, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for custodial care provided on June 27, 2022, to September 23, 
2022. 
 
You asked the Plan to pay for custodial care. You say that you needed these services. The Plan denied your 
request. The Plan says custodial care is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of custodial care have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. Therefore, we decided that the Plan does not have to pay for custodial care 
provided on June 27, 2022, to September 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that a CGM is medically necessary. The Plan denied your 
request. The Plan says medical records were requested, but never received. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 a CGM have been met. Medical records were not provided. Without medical records medical necessity cannot be verified. Therefore, we 
decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on October 20, 
2022. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says durable medical equipment is 
not covered for use outside the home. 
 
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 pay for the durable medical equipment provided on October 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network (OON) 
provider on November 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 dental services provided by an out-of-network (OON) provider on November 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shower chair. 
 
You asked the Plan to pay for a shower chair. You say that the shower chair is medically necessary to prevent 
you from falling in the shower. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
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 pay for a shower chair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an angiography (75710) provided on October 6, 2022. 
 
You asked the Plan to pay for the angiography. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this code 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. 
 
We find that CPT code 75710 is not supported in the medical record. Specifically, the angiography is inclusive 
to the primary revascularization procedure also billed (37226). Based on this information, we decided that 
Medicare rules for coverage of the angiography have not been met. Therefore, we decided that the Plan does 
not have to pay for an angiography (75710) provided on October 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) device provided 
on November 28, 2022. 
 
You asked the Plan to pre-approve a CGM. You say that a CGM is medically necessary. The Plan denied your 
request. The Plan says the medical criteria for a CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not require 
frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this 
information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a continuous glucose monitor (CGM) device provided on November 
28, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for radiological services provided on October 5, 2022, billed with code 
73564. 
 
You asked the Plan to pay for radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says that this claim was billed with an invalid 
diagnosis. 
 
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 specific denial rationale offered by the plan is not supported. 
This claim was billed with the appropriate primary diagnosis, and the records do not indicate that the use of 
diagnosis code M89.9 is incorrect. As such, we find that the denial of payment on this basis is not 
substantiated. Therefore, we decided that the Plan has to pay for radiological services provided on October 5, 
2022, billed with code 73564.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom 6 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that a CGM is medically necessary. The Plan denied your 
request. The Plan says the medical criteria for a CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results. and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, or require frequent 
self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we 
decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Dexcom 6 continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on September 28, 2022, billed 
with code 71045-26. 
 
You asked the Plan to pay for radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this claim was billed with the incorrect place of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that the place of service code assigned should reflect 
the setting in which the service is provided.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of radiology services provided have not been met. The records show that the enrollee was an inpatient 
on the date of service. As such, the POS code 22 is not appropriate. Therefore, we decided that the Plan does 
not have to pay for radiological services provided on September 28, 2022, billed with code 71045-26.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pin retention (D2951) for tooth #12 provided on 
December 15, 2022. 
 
You asked the Plan to pay for the dental service. You say that you had a root canal done and the pin retention 
holds the tooth in place and was needed. The Plan denied your request. The Plan says the denial of payment for 
this service is correct, because the pin retention 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the pin 
retention (D2951) for tooth #12 provided on December 15, 2022.