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

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service July 26, 
2022.  
 You asked the Plan to pay for procedure code 76642. You say that both breasts were imaged due to bilateral 
breast pain. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with two units with a unilateral 
modifier instead of billing one line item with the bilateral modifier as is required. Based on this information, 
we decided that Medicare rules for coverage of procedure code 76642 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76642 billed for date of service July 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3020).  
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3020).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided on January 18, 2023, to, 
March 30, 2023. 
 
You asked the Plan to pay for acupuncture services. You say that you are presently getting treatments and want 
to continue to do the treatments as they are helping your back because you are trying to avoid doing surgery. 
The Plan denied your request. The Plan says that acupuncture is only covered for chronic low back pain. 
 
  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, your diagnosis is low back pain unspecified and 
acupuncture services are only covered for chronic low back pain. Therefore, we decided that the Plan does not 
have to pay for acupuncture services provided on January 18, 2023, to, March 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic shoes (A5500) and inserts (A5513). 
 
You asked the Plan to pre-approve the diabetic shoes and inserts. You say that your doctor referred you to this 
provider because they have the type of shoes your doctor recommended. You also say that you have received 
the diabetic shoes and inserts from this provider for the last 3 years and had no problems until you switched 
health plans. The Plan denied your request. The Plan says medically necessary care is available in-network 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
diabetic shoes (A5500) and inserts (A5513).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on July 11, 2023 
 
You asked the Plan to pay more for the dental services. You say that you believe the Plan should pay more. 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 dental services provided on July 11, 2023
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit and the debridement provided on June 22, 
2023. 
 
You asked the Plan to pay for the home visit and the debridement. You say that you say that the service was 
medically necessary. 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 the home visit and the 
debridement provided on June 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the care management services provided on June 30, 2023. 
 
You asked the Plan to pay for the care management services. You say that you are requesting reconsideration 
of the denied claim. 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 the care management 
services provided on June 30, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical dressings billed with code A6209 for date of service 
July 10, 2023. 
 
You asked the Plan to pay for the surgical dressings. You say that these items were appropriate and should be 
covered. The Plan denied your request. The Plan says you did not bill these supplies with the required modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that rules state that when surgical dressings are billed, 
the appropriate modifier (A1 - A9, AW, EY, or GY) must be added to the code when applicable. 
 
In this case, you did not bill the surgical dressings in dispute with one of the required modifiers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the surgical dressings have not been met. Therefore, we decided that the Plan does not have to pay 
for surgical dressings billed with code A6209 for date of service July 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings provided on May 10, 2023. 
 
You asked the Plan to pay for the compression stockings. You say that you do not agree with the denial of 
payment for the compression stockings because they are a covered benefit. The Plan denied your request. The 
Plan says your provider is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the compression stockings provided on 
May 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203), electrical stimulation (97014), and 
hot or cold packs therapy (97010) provided by a chiropractor on August 8, 2023. 
 
You asked the Plan to pay for the office visit (99203), electrical stimulation (97014), and hot or cold packs 
therapy (97010). You say that you were not aware that you were going to be billed for the office visit. The Plan 
denied your request. The Plan says the only covered chiropractic service is manual manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99203), electrical stimulation (97014), and hot or cold packs 
therapy (97010) provided by a chiropractor on August 8, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit provided on June 16, 2023. 
 
You asked the Plan to pay for home visit. You say that you are appealing the claim payment denial. 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 home visit provided on 
June 16, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nail debridement provided on July 11, 2023. 
 
You asked the Plan to pay for nail debridement. You say that you are appealing the claim payment denial. 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 nail debridement 
provided on July 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the lab services and genetic analysis 
procedure on May 18, 2023.  
 
You asked the Plan to waive the cost share for the lab services and genetic analysis procedure. You say that 
you are asking for the services be processed as in-network. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $10 copayment per provider per day for Medicare-covered lab services. The enrollee must pay a 
20% of the total allowed amount for Medicare-covered diagnostic tests (such as EKG and EEG) and 
procedures. The provider billed in the amount of $393 and the allowed amount is $175.40. For the service it's, 
$175.40 x 20% = $35.08. For both services it's, $10 + $35.08 = $45.08. Therefore, results in the total cost 
sharing amount of $45.08. 
 
The enrollee has been asked to pay a $10 copayment for the lab services and a 20% coinsurance for the genetic 
analysis procedure. This item/service falls within the outpatient diagnostic tests and therapeutic services and 
supplies benefit category. This means that the enrollee has been asked to pay the correct amount based on the 
contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in 
the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the lab services and 
genetic analysis procedure on May 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 1, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 9, 2023. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
August 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (99183, G0277). 
 
You asked the Plan to pre-approve HBO therapy. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that program reimbursement for HBO therapy will be 
limited to that which is administered in a chamber (including the one man unit) and is limited to certain 
conditions. 
 
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 HBO therapy. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found hyperbaric oxygen therapy does not 
have sufficient data to be supported for the use of interstitial cystitis. For this reason, this treatment is neither 
reasonable nor 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 HBO therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen (HBO) therapy (99183, G0277).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on July 25, 2023. 
 
You asked the Plan to pay for dental services. You say that these services were needed. The Plan denied your 
request. The Plan says the enrollee did not have dental coverage at the time of these services. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for dental services provided on July 
25, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (22514). 
 You asked the Plan to pre-approve percutaneous vertebral augmentation. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that PVA (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP)) is covered in patients who meet specific criteria. 
 
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 percutaneous vertebral augmentation. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no 
documented trial of bracing. More conservative measures are needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous vertebral augmentation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve percutaneous vertebral augmentation (22514).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
July 18, 2023. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that that you are on a 
fixed income and cant afford to pay the copay and you have never had to pay for the emergency room visits 
before and all the hospital did was check your blood pressure. 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 $49 
copayment for emergency care. 
 
You have been asked to pay a $49 copayment for the emergency room services. This item/service falls within the emergency 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 the emergency room 
services provided on July 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes G0453 and 95940 billed for date of service 
June 12, 2023. 
 
You asked the Plan to pay for procedure codes G0453 and 95940. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for codes G0453 and 95940 are bundled into 
payment for other codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
G0453 and 95940 are column II codes to column I code 95955. While code G0453 was billed with the modifier 
-59, the medical records provided do not show that the service billed with the -59 modifier is a distinct 
procedural service. 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 codes G0453 and 95940 billed for date of service June 
12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on June 15, 2023. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says these services have been correctly denied. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for dental services provided on June 
15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve patent foramen ovale (PFO) closure device placement 
(93580). 
 
You asked the Plan to pre-approve PFO closure device placement. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 PFO closure device placement. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found clinical studies have shown significantly higher per-procedural 
complications in older age groups; hence guidelines do not recommend PFO closure in patients over age 60. As such, guidelines would not support the need for a PFO closure device. In summary, there is insufficient 
documentation to support the medical necessity for the requested PFO closure in this enrollees clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PFO closure device placement have not been met. Therefore, we decided that 
the Plan does not have to pre-approve patent foramen ovale (PFO) closure device placement (93580).