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

 
We decided that the Plan does not have to pay for an unspecified removable prosthodontic procedure (D5899), 
and a maxillary partial denture (D5213) provided on July 31, 2023. 
 
You asked the Plan to pay for the dental services. You say that you believe the Plan should pay for this. The 
Plan denied your request. The Plan says your annual dental allowance amount 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 annual dental allowance amount was exhausted on date of service July 31, 2023. Therefore, we 
decided that the Plan does not have to pay the remaining balance for an unspecified removable prosthodontic 
procedure (D5899), and a maxillary partial denture (D5213) provided on July 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chiropractic manipulative treatment 
provided on September 08, 2023, to September 11, 2023. 
 
You asked the Plan to waive the coinsurance for chiropractic manipulative treatment. You say that you do not 
agree with the cost sharing. 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 30% 
coinsurance for out-of-network Medicare-covered chiropractic services. 
 
You have been asked to pay 30% coinsurance for chiropractic manipulative treatment. This item/service falls 
within the out-of-network Medicare-covered chiropractic services 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. The total you owe is $20.90 ($69.66 allowed 
amount x 30% = $20.90 rounded up). Therefore, we decided that the Plan does not have to waive the 
coinsurance for chiropractic manipulative treatment provided on September 08, 2023, to September 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 49999 rendered on October 5, 2022. 
 
You asked the Plan to pay for the services. You say that this charge has been properly submitted according to 
all recognized coding standards and guidelines. The Plan denied your request. The Plan says this was 
incorrectly coded and 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 code 49999 is ""Unlisted procedure, abdomen, peritoneum and 
omentum." 
 
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 CPT 49999 is not supported. The record does not support that a separately reportable unlisted procedure was performed. 
 
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 procedure code 49999 rendered on October 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the monitored anesthesia care (MAC) (01992) provided on 
December 21, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the required modifier 
was not used. 
 
The Plan must follow Medicare rules. Medicare rules say that when code 01992 is used and MAC has been 
provided, the QS modifier must be used. 
 
We looked at the file and Medicare rules. As code 01992 was billed in this case for monitored anesthesia care, 
the QS modifier is required. 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 monitored 
anesthesia care (MAC) (01992) provided on December 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the discharge services (99316) provided on May 10, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 99316 is "Nursing facility discharge day management; 
more than 30 minutes". 
 
We find that CPT code 99316 is not supported in the medical record. Specifically, the records do not show that 
nursing facility discharge services were provided for more than 30 minutes on the date in question. Based on 
this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we 
decided that the Plan does not have to pay for the discharge services (99316) provided on May 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64629, 64628). 
 
You asked the Plan to pre-approve an Intracept procedure. 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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is experimental. There is no magnetic resonance imaging 
(MRI) showing only modic chnages without facet degenerative joint disease or stenosis. The cause of the pain 
is not clear.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64629, 64628).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for continuous glucose monitor (CGM) 
device (A4239) provided July 18, 2023. 
 
You asked the Plan to pay for the CGM supplies. You say that please review the appeal letter and process the 
claim. The Plan denied your request. The Plan says the items were purchased from a supplier that is not 
enrolled in Medicare as a durable medical equipment supplier. 
 
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 supply allowance for continuous 
glucose monitor (CGM) device (A4239) provided July 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingivectomy (D4211) provided on November 3, 2023. 
 
You asked the Plan to pay for the dental service. You say that a cap came off of your tooth. You say that you 
went to your dentist to have it put back on. You also say that had to be done so the cap would set correctly. The 
Plan denied your request. The Plan says this is not a covered benefit. 
 
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 service at issue is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the gingivectomy 
(D4211) provided on November 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF testing (81455) provided on July 18, 2023. 
 
You asked the Plan to pay for the Tempus xF testing. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this test is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF test is not FDA approved. Based 
on this information, we decided that Medicare rules for coverage of the Tempus xF testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the Tempus xF testing (81455) provided on July 
18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99214) provided on July 
25, 2023. 
 
You asked the Plan to waive the copayment for the office visit (99214). You say that the cost share is wrong. 
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 $40 
copayment for urgently needed services. 
 
You have been asked to pay a $40 copayment for the office visit (99214). This item/service falls within the 
urgently needed services 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 office 
visit (99214) provided on July 25, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colonoscopy and the injection services provided on 
August 21, 2023. 
 
You asked the Plan to pay for the colonoscopy and the injection 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 colonoscopy and the injection services provided on August 21, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan must waive the copayment for the inpatient hospital stay provided on August 18, 
2023, to August 31, 2023.  
 
You asked the Plan to waive the copayment for the hospital stay. You say you disagree with the copayment due 
to the service that was provided to during the hospital stay. The Plan denied your request. The Plan says that 
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 enrollees must pay a $0 copayment for inpatient hospital care and inpatient 
services in a psychiatric hospital. 
 
The Plan says you must pay $1,650 copayment for the inpatient hospital care. Based on the Plan contract, 
however, you cannot be asked to pay more than a $0 copayment for inpatient hospital care and inpatient 
services in a psychiatric hospital. Therefore, we decided that the Plan must waive the copayment for the 
inpatient hospital stay provided on August 18, 2023, to August 31, 2023.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (87798) provided on May 31, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 87798 is "Infectious agent detection by nucleic acid 
(DNA or RNA), not otherwise specified; amplified probe technique, each organism". 
 
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 use of code 87798 is 
not supported by the records. Our reviewer found that the documentation does not contain information 
regarding which infectious agents were tested for and reported with this unlisted code.  
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 services (87798) provided on May 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88177 billed for date of service September 
18, 2023.  
 
You asked the Plan to pay for procedure code 88177. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88177 is 6. The MAI value for this code is 3. You billed 7 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88177 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88177 billed for date of service September 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) and appliances 
(E0673, E0668) provided November 24, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliances. You say that please find 
attached the medical necessity and risk assessment document supplied by the doctor for this procedure. The 
Plan denied your request. The Plan says claims for E0676 are not covered by Medicare. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676) and appliances (E0673, E0668) provided November 24, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services to be provided by OON provider.  
 
You asked the Plan to pre-approve home health services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says you are not homebound. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 home health services. Our reviewer says that the requested services are not medically necessary. Our physician reviewer found the requested services do not appear to be emergent or 
urgent. As such, the use of an OON provider is not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met.  
 
The Plan has network providers available who are capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) We found no exception that would require the Plan to pre-approve home health services. 
Therefore, we decided that the Plan does not have to pre-approve home health services to be provided by an 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eye exams provided from August 25, 2023, to September 1, 
2023. provided on August 25, 2023, to September 01, 2023. 
 
You asked the Plan to pay for eye exams provided from August 25, 2023, to September 1, 2023.. You say that 
you do not know where to go for your eye exams and glasses. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage rules that apply.) 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 eye exams provided from August 25, 2023, to September 1, 2023. provided on August 25, 2023, to 
September 01, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor supplies billed for date of 
service July 25, 2023. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. The medical records do not show that a continuous glucose 
monitor was part of the treatment plan for the enrollees condition. Based on this information, we decided that 
the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay 
for the continuous glucose monitor supplies billed for date of service July 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections for pain management. 
 You asked the Plan to pre-approve epidural steroid injections for pain management. You say that it is medically 
necessary. The Plan denied your request. The Plan says it is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that ESI is covered when the criteria listed in the 
Medicare rules section is met. 
 
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 epidural steroid injections for pain 
management. Our reviewer says that the service is not medically necessary. Our physician reviewer found a 
repeat epidural steroid injection (ESI) is indicated when the first injection directly and significantly provided 
improvement of the condition being treated, may be considered medically reasonable and necessary when the 
medical record documents at least 50% of sustained improvement in pain relief and/or improvement in function 
measured from baseline using SAME scale for at least 3 months. If a enrollee fails to respond well to the initial 
ESI, a repeat ESI after 14 days can be performed, using a different approach, level and/or medication if 
appropriate, with the rationale and medical necessity for the second ESI documented in the medical record. 
This request is for a series of three (3) ESIs. It is not medically reasonable or necessary to prescribe a 
predetermined series of ESIs. The review has determined that the enrollee does not meet the coverage 
indications for the procedures. The enrollee does not meet any of the limitations/exclusions for this request. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injections for pain management have not been met. Therefore, 
we decided that the Plan does not have to pre-approve epidural steroid injections for pain management.