Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided on August 15, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have submitted proof of 
delivery along with other supporting documentation, but the claim keeps denying for missing this information. 
The Plan denied your request. The Plan says the provider 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 a continuous 
glucose monitor (CGM) provided on August 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on June 16, 2022, billed with 
procedure code 99233. 
 
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 is billed with an inappropriate place of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that the place of service (POS) code is generally used 
to reflect the actual setting where the beneficiary receives the face-to-face service. 
 
We looked at the file and Medicare rules. We find that the claim is inappropriately billed with POS of 21 as the 
claim history shows that the enrollee was registered as outpatient observation status on the date of service in 
question. Based on this information, we decided that Medicare rules for coverage of the practitioner services 
provided have not been met. Therefore, we decided that the Plan does not have to pay for practitioner services 
provided on June 16, 2022, billed with procedure code 99233.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CxBladder testing (0012M) provided on December 15, 2022. 
 
You asked the Plan to pay for the CxBladder testing. You say that this test was medically necessary. The Plan 
denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare has reaffirmed non-coverage for CPT 
codes 0012M and 0013M for CxBladder. 
 
We looked at the file and Medicare rules. The testing performed was CxBladder, code 0012M. This service is 
non-covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of 
the CxBladder testing have not been met. Therefore, we decided that the Plan does not have to pay for 
CxBladder testing (0012M) provided on December 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on July 14, 2023. 
 
You asked the Plan to pay for wound care supplies. You say that these supplies were 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 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 wound care supplies provided on July 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the manual therapy (97140) provided on September 6, 2023 
and September 23, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not covered by Medicare or 
the Plan.  
 
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 services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the manual therapy (97140) provided on September 6, 2023 and 
September 23, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital inpatient or observation discharge (99239) 
provided on February 1, 2023. 
 
You asked the Plan to pay for the inpatient or observation discharge. You say that the service was billed 
correctly and should be paid. The Plan denied your request. The Plan says the medical records submitted dont 
include hospital inpatient or observation discharge day management note for the billed date of service. 
Therefore, code 99239 is not supported. 
 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 inpatient or observation discharge 
have been met. The medical records did not show the hospital inpatient or observation discharge for the date of 
service (DOS) that is being appealed. Therefore, we decided that the Plan does not have to pay for the hospital 
inpatient or observation discharge (99239) provided on February 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dressing supplies provided on April 07, 2023. 
 
You asked the Plan to pay for the dressing supplies. You say that you are asking for the review of the submitted 
documents. 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 dressing supplies provided on April 07, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
July 14, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you were not 
treated by a doctor and should not owe this copayment. 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 $125 
copayment for emergency services. 
 
You have been asked to pay a $125 copayment for an emergency room (ER) visit. This item/service falls 
within the emergency 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 an 
emergency room (ER) visit provided on July 14, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service May 9, 2023. 
 You asked the Plan to pay for procedure code 93042. You say that the service was billed correctly and should 
be paid. The Plan denied your request. The Plan says payment for code 93042 is bundled into payment for code 
93010. 
 
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 93042 
is a column II code to column I code 93010. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 93042 billed for date of service May 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified removable prosthodontic procedure (D5899) 
provided on September 29, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were not informed that this procedure is not 
a covered benefit. The Plan denied your request. The Plan says this service is not a covered benefit under your 
dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
unspecified removable prosthodontic procedure (D5899) provided on September 29, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hysterectomy provided on September 19, 2023. 
 
You asked the Plan to pay for a hysterectomy. You say that the coding that was used and correct, this should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The 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 a hysterectomy provided on September 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 29, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for office visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this provider is out-of-network with the Plan and authorization was not 
obtained. 
 
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/service at issue. We found no exception that would 
require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an 
office visit provided on August 29, 2023, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
October 06, 2022, to October 07, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you would like it 
removed since the second visit was for the same condition. 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 $375 
copayment for inpatient hospital care. 
 
You have been asked to pay a $375 copayment for the 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. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient 
hospital stay provided on October 06, 2022, to October 07, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
September 12, 2023. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you were not given a 
choice and did not initiate to be taken by ambulance. 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 $200 
copayment for ambulance services. 
 
You have been asked to pay a $200 copayment for the ambulance services. This item/service falls within the 
ambulance 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 ambulance 
services provided on September 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual routine preventive physical exam provided on 
October 10, 2023. 
 
You asked the Plan to pay for the annual routine preventive physical exam. The Plan denied your request. The 
Plan says annual routine preventive physical exams are covered once every calendar year. The member 
previously had a preventative physical exam on August 29, 2023. 
 
The Plan contract says that non-Medicare covered routine physical exams are covered once every calendar 
year.  
 
We looked at the file and the Plans rules. The file shows that you have exceeded the benefit limit. Based on 
this information, we decided that the Plans rules for coverage of the annual routine preventive physical exam 
have not been met. Therefore, we decided that the Plan does not have to pay for an annual routine preventive 
physical exam provided on October 10, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care on 
August 1, 2023, to August 15, 2023. 
 
You asked the Plan to waive the copayment for the skilled nursing facility (SNF) care. You say that you don't 
feel that you should have to pay the copayment for the SNF stay provided because the member was not taken 
care of properly at the facility. 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 $0 copayment per day for days 1-20 and a $196 copayment per day for days 21-100. For this visit 
there were fifteen days. For the service it's, 15 x $196 = $2,940. Therefore, results in the total cost sharing 
amount of $2,940. The enrollee has been asked to pay a $196 copayment per day for the skilled nursing facility (SNF) care. This 
item/service falls within the skilled nursing facility (SNF) care 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 copayment for the skilled nursing facility (SNF) care on August 1, 2023, to August 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the walking boot provided on June 27, 
2023. 
 
You asked the Plan to waive the coinsurance for the walking boot. You say that you want to appeal the amount 
being charged. 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 20% 
coinsurance for prosthetic devices and related supplies. 
 
You have been asked to pay 20% coinsurance for the walking boot. This item/service falls within the prosthetic 
devices and related supplies 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 $42.58 ($212.89 allowed amount x 20% = $42.58). Therefore, we 
decided that the Plan does not have to waive the coinsurance for the walking boot provided on June 27, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a psychiatric diagnostic evaluation provided on August 8, 2023. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that this provider is Medicare 
eligible and the services were medically necessary. The Plan denied your request. The Plan says that Masters of 
Social Work are not eligible to enroll in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the Plan has not provided a Medicare rule to substantiate their 
denial for services provided by a Licensed Clinical Social Worker. Therefore, we decided that the Plan has to 
pay for a psychiatric diagnostic evaluation provided on August 8, 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on July 14, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the provider must attempt to consult the attending or primary care physician 
about the services furnished and document the consent or declination date to consultations, and the date of 
consultations in the patients medical record. There was no documentation of contact in the patient record.   
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on July 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the periodic oral evaluation (D0120) and the 
dental cleaning (D1110) provided on October 10, 2023. 
 
You asked the Plan to issue reimbursement for the dental services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says your benefit for 
the services provided 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 services provided was exhausted on date of service July 11, 2023.  
  
 
Specifically, the Plans contract states that two periodic oral exams and two dental cleanings are covered per 
calendar year. You previously received these services on March 7, 2023 and July 11, 2023 accordingly, less 
than one year prior, which were paid for by the Plan. Therefore, you have exhausted the allowable benefit for 
the services provided in this case. Therefore, we decided that the Plan does not have to issue reimbursement for 
the periodic oral evaluation (D0120) and the dental cleaning (D1110) provided on October 10, 2023.