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

 
We decided that the Plan does not have to pay for practitioner services provided on June 12, 2023, billed with 
procedure codes 71045, R0075-UN, and Q0092. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim has billing errors; a corrected claim must 
be submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the practitioner services provided have 
been met. Specifically, a corrected claim must be submitted in order for the claim to be reprocessed. Therefore, 
we decided that the Plan does not have to pay for practitioner services provided on June 12, 2023, billed with 
procedure codes 71045, R0075-UN, and Q0092.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services described by code 
99221 billed for date of service June 23, 2023.  
 
You asked the Plan to pay for 99221. You say that 99221 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says 99221 is denied because it is not supported in the 
documentation.  
 
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 99221 is not supported in the medical record. Specifically, we confirmed that the 
records provided do not include documentation of an evaluation and management service performed June 23, 
2023. The evaluation and management encounter notes included in the case file have the date of service listed 
as June 24, 2023. Based on this information, we decided that Medicare rules for coverage of 99221 have not been met. Therefore, we decided that the Plan does not have to pay for the evaluation and management services 
described by code 99221 billed for date of service June 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home blood pressure monitor. 
 You asked the Plan to pre-approve the home blood pressure monitor. You say that this item is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve a home blood pressure monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an in-network exception for an office visit to be 
provided by the requested provider. 
 
You asked the Plan to pre-approve an in-network exception for an office visit to be provided by the requested 
provider. You say that you were seen by an out-of-network provider for cancer treatment in 2019 and you 
request to see the same provider for a new issue of sinus congestion. The Plan denied your request. The Plan 
says there are in-network providers in the region with no evidence that in-network specialist resources in the 
same geography to the member have been exhausted.  
 
The Plan contract says you can choose to receive care from out-of-network providers. However, if you use an 
out-of-network provider, your share of the costs for your covered services may be higher. 
 
We looked at the file and the Plans rules. The Plan contract says you can choose to receive care from out-of-
network providers. However, if you use an out-of-network provider, your share of the costs for your covered 
services may be higher. Therefore, we decided that the Plan does not have to pre-approve an in-network 
exception for an office visit to be provided by the requested provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair accessories (K0108). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that these features are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules also say that duplicate items are not covered.  
 
The tablet holder 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. This item is 
non-covered. The remaining wheelchair accessories were already approved with the power wheelchair. 
Duplicate items are not covered. Therefore, we decided that the Plan does not have to pre-approve wheelchair 
accessories (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete mandibular denture (D5120) provided on June 
13, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were told the dentures would 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 a complete mandibular denture (D5120) provided on June 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on August 2, 2023. 
 
You asked the Plan to pay for the dental services. You say that you feel like the Plan should pay for this. 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 on August 2, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve group psychotherapy to be provided by an  
out-of-network provider.  
 
You asked the Plan to pre-approve group psychotherapy. The Plan denied your request. The Plan  
says that, with limited exceptions, members of the Plan must use network providers to get medical care and 
services. The only exceptions are emergencies, urgently needed care when the network is not available  
out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve group 
psychotherapy to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0669) to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the pneumatic compression device. You say that this item is medically 
necessary. The Plan denied your request. The Plan says there are network providers available. 
 
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 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 a 
pneumatic compression device (E0652, E0669) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pneumatic compression device to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the pneumatic compression device. You say that you really need the 
equipment. The Plan denied your request. The Plan says the enrollee must receive their care from a network 
provider (for more information about this, see Section 2 in Chapter 3). In most cases, care the enrollee receives 
from an out-of-network provider (a provider who is not part of the plans network) will not be 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 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 
the pneumatic compression device to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that you would benefit with this CGM. 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 when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. 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 
Freestyle Libre 3 continuous glucose monitor (CGM).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92557 billed for date of service May 10, 
2023.  
 
You asked the Plan to pay for procedure code 92557. You say that the claim is billed correctly and should be 
paid. 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 cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 92557 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 92557 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 92557 billed for date of service May 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0013M) provided January 30, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0013M) provided January 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam CT (D0365) provided on August 7, 2023. 
 
You asked the Plan to pay for cone beam CT. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for cone 
beam CT (D0365) provided on August 7, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ED services provided on July 6, 2023. 
 
You asked the Plan to pay for the ED services. You say that this should be covered. The Plan denied your 
request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the ED 
services provided on July 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Koya Dayspring Device (K1024, K1003). 
 
You asked the Plan to pre-approve the Koya Dayspring Device. You say that please review the attached 
records and clinical evidence to reconsider the decision to deny coverage. The Plan denied your request. The 
Plan says this is considered experimental and investigational due to insufficient evidence of efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We looked at the file, and Medicare rules. There is insufficient evidence in the medical literature to 
demonstrate that the Koya Dayspring Active Compression Garment System is an effective treatment modality 
for the treatment of lymphedema, providing lasting relief, as compared to other treatment modalities.  Based on 
this information, we decided that Medicare rules for coverage of the Koya Dayspring Device have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the Koya Dayspring Device (K1024, 
K1003).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on January 20, 2022 to 
February 15, 2022. 
 You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 20, 2022. The NOA was not received by the Plan until October 7, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
on January 20, 2022 to February 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the inpatient hospital care provided on July 
17, 2023.  
 
You asked the Plan to waive the cost share for the inpatient care. You say that you were not provided with a 
logical explanation on why this was not covered. 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. Your 
contract with the Plan says that there is a $1000 deductible which applies to inpatient hospital care.  
 
The item or service you asked the Plan to waive the cost share for falls within the inpatient hospital care benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 
deductible which applies to certain medical services. This cost sharing is a contractual obligation that had not 
been met at the time the inpatient care was received on July 17, 2023. Therefore, we decided that the Plan does 
not have to waive the cost share for the inpatient hospital care provided on July 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77300-XS billed for date of service March 
28, 2023.  
 
You asked the Plan to pay for procedure code 77300-XS. You say that the claim is billed correctly and should 
be paid. The Plan denied your request. The Plan says payment for code 77300-XS is bundled into payment for 
code 77307. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 
77300-XS is a column two code to column one code 77307 with a modifier indicator of 0. The column two 
code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 77300-XS billed for date of 
service March 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance procedures (D4910) provided on 
August 3, 2023. 
 
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 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 January 17, 2023, and 
April 13, 2023. Therefore, we decided that the Plan does not have to pay for periodontal maintenance 
procedures (D4910) provided on August 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9999 and A9270 billed for date of service 
April 19, 2023. 
 
You asked the Plan to pay for procedure code S9999. You say that this should be paid for. The Plan denied 
your request. The Plan says the billed codes are invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9999 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9999 is not valid for Medicare purposes. Additionally, the definition of A9270 is "non-
covered item or service" therefore this code is also not covered. Based on this information, we decided that Medicare rules for coverage of procedure code S9999 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code S9999 and A9270 billed for date of service April 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical each radiographic image (D0230) 
provided on February 20, 2023. 
 
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 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 February 20, 2023. 
Therefore, we decided that the Plan does not have to pay for intraoral - periapical each radiographic image 
(D0230) provided on February 20, 2023.