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

 
We decided that the Plan does not have to pay more for extractions (D7140 x4, D7210 x2), a lower immediate 
denture (D5140), and an upper complete denture (D5110) provided on September 22, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you thought the provider was in-network. 
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. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 extractions (D7140 x4, D7210 x2), a lower 
immediate denture (D5140), and an upper complete denture (D5110) provided on September 22, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 13, 2022. 
 
You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says the member 
was enrolled in hospice on this date of service. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for laboratory services provided on June 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a digital, binaural, hearing aid (V5261) provided on August 
1, 2022. 
 
You asked the Plan to pay for a digital, binaural, hearing aid (V5261). You say that you tried to schedule an 
appointment with two Plan specific providers, but they did not carry the brand you like. The Plan denied your 
request. The Plan says the EOC states that hearing aids must be purchased through the Plan hearing vendor in 
order for it to be covered. The Plan also says that the enrollee did not purchase the hearing aids through the 
Plan hearing vendor, therefore the Plan will continue to deny reimbursement for this service. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan covers 
hearing aids only when you schedule your appointments through the Plan hearing provider.  
 
 
  We looked at the file, and the Plan's rules. The Plan rules say that they cover hearing aids only when you 
schedule your appointments through the Plan hearing provider. The Plan rules also say that if you choose to 
schedule an appointment directly with a provider, your services will not be covered. Based on this information, 
we decided that the Plan's rules for coverage of a digital, binaural, hearing aid (V5261) have not been met. 
Therefore, we decided that the Plan does not have to pay for a digital, binaural, hearing aid (V5261) provided 
on August 1, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 45385 provided on August 1, 2022. 
 
You asked the Plan to pay for procedure code 45385. 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 the Medicare approved amount for global 
surgery procedures includes payment for the above services related to the surgery when furnished by the 
physician who performs the surgery. 
 
We looked at the file and Medicare rules. The procedure in question was provided within the 90-day global 
period for the surgical procedure (code 46255) that was provided on June 11, 2022. Code 45385 was not billed 
with a modifier indicating this was unrelated to the original procedure. This means that payment for the 
procedure was included in the payment for the original surgical procedure. Therefore, we decided that the Plan 
does not have to pay for procedure code 45385 provided on August 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom breast prosthesis. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a custom fabricated prosthesis (L8035) is denied as not 
medically necessary. 
 
We looked at the file and Medicare rules. The item at issue is a custom fabricated prosthesis described by code 
L8035. This item is denied by Medicare. The Plan has approved a mastectomy bra with prosthetics. Therefore, 
we decided that the Plan does not have to pre-approve a custom breast prosthesis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 provided on May 10, 2022. 
 
You asked the Plan to pay for procedure code 99153. 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. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. In this case, the review shows that the medical records provided represent professional charges; however, procedure code 99153 was provided in a facility with a place of 
service code of 22. Procedure code 99153 has a PC/TC Modifier Status of 3, which specifies a Technical 
Component only code. Therefore, we decided that the Plan does not have to pay for procedure code 99153 
provided on May 10, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for diagnostic radiology services provided on August 2, 2022. 
 
You asked the Plan to pay for diagnostic radiology services. You say that no authorization is needed. The Plan 
denied your request. The Plan says that this service was not authorized. 
 
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 has not provided us with the Medicare rule or the Plans 
rule to support their denial. Therefore, we decided that the Plan has to pay for diagnostic radiology services 
provided on August 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 physician's services provided by an out-of-network provider 
on August 17, 2022. 
 
You asked the Plan to pay for physician's services. You say that you saw this provider in August and 
September of 2021 and the claims were paid as in-network. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 physician's services provided by an out-of-network provider on 
August 17, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on July 5, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says the Plan requires 
utilization of network providers when possible and available and requires authorization for certain services. No 
medical necessity for an out-of-network provider such as an urgent or an emergent situation that has been 
documented.   
 
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 psychotherapy provided on July 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power scooter (K0806). 
 
You asked the Plan to pre-approve the group 2 power scooter. You say that this scooter is medically necessary. 
The Plan denied your request. The Plan says records show this scooter is for use outside the home, and it is 
therefore non-covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a group 2 power scooter (K0806).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthroscopy, knee, surgical; synovectomy, major, 2 or more 
compartments (eg, medial or lateral) provided to the enrollee on August 18, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied code is not supported by the medical records submitted. 
 
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 29876 is "Arthroscopy, knee, surgical; synovectomy, 
major, 2 or more compartments (eg, medial or lateral)." 
 
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. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the records do not support that 
CPT 29876: arthroscopy, knee, surgical, synovectomy, major 2 or more compartments (e.g., medial or lateral) 
was rendered in this case. The patient was being treated for other synovitis and tenosynovitis of the right lower 
leg. The enrollee underwent a right knee arthroscopy, lateral retinacular release, patellofemoral and medial chondroplasty, patellofemoral and medial synovectomy, and synovectomy of the patellofemoral and medial 
compartments on 8/18/22. The procedure report cites the arthroscopic shaver was used to perform synovectomy 
of the anterior and medial compartments as well as chondroplasty of the patellofemoral and medial 
compartments. There is no indication that the lateral compartment was involved. 
 
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 have not been met. Therefore, we decided that the Plan does not 
have to pay for arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or 
lateral) provided to the enrollee on August 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bladder catheter insertion provided on April 06, 2022. 
 
You asked the Plan to pay for bladder catheter insertion. You say that the service rendered was medically 
necessary and previously paid on a separate date of service. 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 bladder catheter 
insertion provided on April 06, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for a filling (D2335), a crown (D2740), 
and a core buildup (D2950) provided on August 29, 2022. 
 
You asked the Plan to pay an additional amount for the dental services. You say that because the services were 
pre-approved you understood that they would be covered. 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 August 29, 2022. 
Therefore, we decided that the Plan does not have to pay an additional amount for a filling (D2335), a crown 
(D2740), and a core buildup (D2950) provided on August 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided on 
November 05, 2021, to November 09, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you cannot afford this 
charge. 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 a $100 
copayment for Inpatient hospital care. 
 
You have been asked to pay a $100 copayment for inpatient hospital stay. This item/service 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. You have been asked to pay a total copayment of $400 ($100 x 4 days) for your inpatient 
stay. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital stay 
provided on November 05, 2021, to November 09, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right knee replacement procedure. 
 
You asked the Plan to pre-approve a right knee replacement procedure. You say that the requested right knee 
replacement is medically necessary. The Plan denied your request. The Plan says the requested right knee 
replacement is not medically necessary. 
 
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 a right knee replacement procedure. 
Our reviewer says that the requested right knee replacement is not medically necessary. Our physician reviewer 
found the enrollee was being treated for primary osteoarthritis of the right knee. He presented with right knee 
pain. The pain has been unchanged. The pain is rated at 2/10 and is dull. Associated symptoms include 
swelling, stiffness, and instability. Height is 6 feet, 233 pounds, and a body mass index of 31.60kg/m2. The 
exam reveals tenderness of the medial joint line. The range of motion is -5 to 130. There is moderate swelling 
and crepitus noted.  
 
However, detailed documentation regarding a trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures including injections is not evident. Additionally, he is noted with a body 
mass index of 31.60kg/m2. There are limited large-scale, long-term references showing the safety and efficacy 
of the requested surgery in this clinical setting. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
right knee replacement, in this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a right knee replacement procedure have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a right knee replacement procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an over-bed table (E0274). 
 
You asked the Plan to pre-approve the over-bed table. You say that this item is medically necessary. The Plan 
denied your request. The Plan says the table is not primarily medical in nature and is non-covered. 
 
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 an over-bed table (E0274).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667). 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show failure of an adequate trial of E0650 or E0651. 
 
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 the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there has not been a failed four-week trial of the basic device. The enrollee does not have 
lymphedema of the chest, trunk, or abdomen. The enrollee does not have unique characteristics that would 
indicate the segmented pump over a standard pump. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0667).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88305 and 88312 billed for date of service 
May 2, 2022. 
 
You asked the Plan to pay for procedure code(s) 88305 and 88312. You say that these services were necessary 
and were reported correctly. The Plan denied your request. The Plan says this code is included in the facility 
payment and is not separately payable. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88305 and 88312. 
This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88305 and 
88312. Based on this information, we decided that Medicare rules for coverage of procedure code 88305 and 
88312 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code(s) 
88305 and 88312 billed for date of service May 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urological services (procedure codes 51798 and 93975) 
provided to the enrollee on May 6, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 93975: 
 
Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal 
organs; complete study 
 
 
 CPT 51798: 
 
Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging 
 
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. Our reviewer says that the services do not 
support that these codes were rendered or supported in this case. Our reviewer found that the records only 
support that CPT 76700 was rendered on this date of service. 
 
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 have not been met. Therefore, we decided that the Plan does not 
have to pay for the urological services (procedure codes 51798 and 93975) provided to the enrollee on May 6, 
2022.