Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 provided on March 6, 2023. 
 
You asked the Plan to pay for procedure code 99233. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if more than one evaluation and management 
(face-to-face) service is provided on the same day to the same patient by the same physician or more than one 
physician in the same specialty in the same group, only one evaluation and management service may be 
reported. 
 
We looked at the file and Medicare rules. The E/M service in question was provided on the same day as E/M 
service (99291) provided by a different provider in the same group. This means that only one E/M service is payable. As code 99291 has already been processed and paid by the Plan, code 99233 is not payable in this 
case. Therefore, we decided that the Plan does not have to pay for procedure code 99233 provided on March 6, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99212 provided on October 11, 2022. 
 
You asked the Plan to pay for procedure code 99212. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that diagnosis codes must be billed with the most precise 
code that most fully explains the narrative description of the symptom or diagnosis. 
 
We looked at the file and Medicare rules. The file shows that procedure code 99212 was billed with one or 
more diagnosis codes that were inappropriately coded. Medicare rules say that some ICD-10-CM codes 
indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. It is not appropriate 
to report left and right and bilateral codes together for the same procedure code. Therefore, we decided that the 
Plan does not have to pay for procedure code 99212 provided on October 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for incomplete endodontic therapy; inoperable, unrestorable or 
fractured tooth (D3332) provided on December 15, 2022. 
 
You asked the Plan to pay for the incomplete endodontic therapy. You say that this service should be covered 
as it was performed to get a diagnosis and was necessary to make a decision. The Plan denied your request. The 
Plan says service D3332 is not included in the list of covered services. 
 
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 incomplete endodontic therapy is  
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
incomplete endodontic therapy; inoperable, unrestorable or fractured tooth (D3332) provided on December 15, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care to be provided after July 4, 2023. You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration of the denied 
authorization. The Plan denied your request. The Plan says the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not require daily skilled nursing or therapy services. The 
enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care to be provided after July 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant 
(D6010), and bone graft at time of implant placement (D6104) provided on January 17, 2023. 
 
You asked the Plan to pay for the dental services represented by codes D4910, D6010 and D6104. You say that 
the crown was repaired due to tooth 20 breaking, the implant was due to extraction of tooth 31, and the 
cleaning was due to you having a history of periodontal disease.  The Plan denied your request. The Plan says these services are not included in your dental coverage when 
received form an in-network or 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. 
 
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 
surgical placement of implant body: endosteal implant (D6010), and bone graft at time of implant placement 
(D6104) provided on January 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481 and 87653 billed for date of service 
December 13, 2022. 
 
You asked the Plan to pay for procedure codes 87481 and 87653. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says payment for codes 87481 and 
87653 are bundled into payment for code 87801. 
 
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 
87481 and 87653 are column II codes to column I code 87801. 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 codes 87481 and 87653 billed for 
date of service December 13, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve the additional 16 occupational therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the services are medically necessary to 
restore function to the enrollee's hand and fingers.  The Plan denied your request. The Plan says that the 
enrollee has reached a plateau in their treatment and have no medical need to continue a professionally 
supervised maintenance program.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the therapy services. Our physician 
reviewer found the therapy is appropriate for the enrollee's condition, the enrollee is responding. The Plan's 
rationale for denial is not consistent with the enrollee's condition or their response to therapy. We looked at this 
physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the therapy services have been met. Therefore, we decided that the Plan has to pre-approve the 
additional 16 occupational therapy visits.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the biopsy services provided on June 10, 
2022. 
 
You asked the Plan to waive the cost share for the biopsy services. You say that your provider wanted to check 
for oral cancer. 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 out-of-network specialist services.  
 
You have been asked to pay $219, which is 20% coinsurance for the biopsy services. This item/service falls within the physician/practitioner 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 cost share 
for the biopsy services provided on June 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the wound care services provided from 
November 1, 2022, to November 29, 2022. 
 
You asked the Plan to reduce the copayment for the wound care services. You say that you did not know you 
would be charged a facility fee. 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 $25 
copayment for wound care provided at an outpatient hospital.  
 
You have been asked to pay a $25 copayment for each wound care service provided on November 1, 2022, 
November 8, 2022, November 15, 2022, November 22, 2022, and November 29, 2022. These items/services 
fall within the outpatient hospital 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 reduce the copayment 
for the wound care services provided from November 1, 2022, to November 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulation (G0283) provided from January 4, 
2023, through January 13, 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 a covered benefit.  
 
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 electrical stimulation (G0283) provided from January 4, 2023, 
through January 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the noninvasive ear or pulse oximetry for oxygen saturation; 
single determination (94760) provided on August 11, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says  the provider did not bill as required by Medicare coding regulations.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Review of the records indicate procedure 94760 has a status indicator of 'T' on the CMS National Physician Fee 
Schedule (NPFS) RVU file. This means this service is always bundled into another payable physician service, 
71045, billed the same day by the same provider. Based on this information, we decided that Medicare rules for 
coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for the 
noninvasive ear or pulse oximetry for oxygen saturation; single determination (94760) provided on August 11, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the infusion services provided on January 
26, 2023. 
 
You asked the Plan to reduce the copayment for the infusion services. You say that the services were provided 
at a remote infusion center. 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 outpatient hospital services. 
 
You have been asked to pay a $200 copayment for the infusion services. This item/service falls within the outpatient hospital services benefit category. This means that you have been asked to pay the correct amount tbased on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The record shows service were rendered by Cleveland Clinic Indian River the Hospital. However, since the allowed amount is less than the standard copayment, you only owe $188.19. Therefore, we decided that the Plan does not have to reduce the copayment for the infusion services provided on January 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377).  
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that the enrollee has 
cerebral palsy and needs the wheelchair for daily functions and activities. The Plan denied your request. The 
Plan says although there are three approved power options on this wheelchair (tilt, recline and elevating leg 
rests), there is not a medical need to control these power options through the joystick.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the durable medical equipment (DME). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the requested electrical accessories are not medically necessary as you 
do have use of the upper extremity and can operate and control the power options using the switches that are 
included in the basic wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4215 provided on December 1, 2022. 
 
You asked the Plan to pay for procedure code A4215. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A4215 has a Status Indicator of X on the Physician Fee Schedule. This means that 
procedure code A4215 is statutorily excluded from Medicare payment. Based on this information, we decided 
that Medicare rules for coverage of procedure code A4215 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code A4215 provided on December 1, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services billed with codes 87581, 87486, 
87541, 87498, 87496, 87651, 87532, 87641, 87798-59, and 87653 for February 8, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services billed with 
codes 87581, 87486, 87541, 87498, 87496, 87651, 87532, 87641, 87798-59, and 87653 for February 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services the intraoral - periapical each additional 
radiographic image (D0230) provided on September 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had no advance warning from the Plan that 
there were additional specific requirements for root planing. You also say that you are respectfully asking that 
you reconsider reimbursing you for the charges you must now pay. The Plan denied your request. The Plan 
says your benefit for the intraoral - periapical each additional radiographic image 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 Plan's 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 intraoral - periapical each additional radiographic image was exhausted on date of 
service September 1, 2022. Therefore, we decided that the Plan does not have pay for the intraoral - periapical 
each additional radiographic image (D0230) provided on September 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2750) provided on January 10, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plan's 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 Plan's coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network provider's charges and the Plan's 
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 a crown (D2750) provided on January 10, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on February 11, 2023.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 99223 remains 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 99233 is "Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit."

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that the documentation from the denied date was not provided. Therefore, without sufficient documentation supporting a comprehensive history and physical or medical decision-making of high complexity for February 11, 2023, the code, 99223, is not supported for this date.

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 initial hospital care (procedure code 99223) rendered on February 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pontic - porcelain fused to noble metal (D6242). 
 
You asked the Plan to pre-approve the pontic - porcelain fused to noble metal, and retainer crown - porcelain 
fused to high noble metal. You say that you are fine with a metal bridge to close the gap, but that was also 
declined and should be reconsidered. The Plan denied your request. The Plan says code D6242 is denied 
because service is not a covered expense under the plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the pontic - porcelain fused to noble 
metal are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve pontic - porcelain fused to noble metal (D6242).