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

 
We decided that the Plan does not have to pay for codes 95937, 95938, 95939, 95955, 95870-26, 95870-26,59, 
and G0453 for date of service February 23, 2023. 
 
You asked the Plan to pay for codes 95937, 95938, 95939, 95955, 95870-26, 95870-26,59, and G0453. You 
say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not 
payable as billed. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. 
 
We find that CPT codes 95937, 95938, 95939, 95955, 95870-26, 95870-26,59, and G0453 are not payable as 
billed. Specifically, these services were billed with diagnosis codes M43.06 and M43.16. Due to an Excludes1 
note, these two diagnosis codes should not be reported together. Based on this information, we decided that 
Medicare rules for coverage of codes 95937, 95938, 95939, 95955, 95870-26, 95870-26,59, and G0453 have 
not been met. Therefore, we decided that the Plan does not have to pay for codes 95937, 95938, 95939, 95955, 
95870-26, 95870-26,59, and G0453 for date of service February 23, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal aortic aneurysm (AAA) screening (76706) 
provided on March 16, 2023. 
 You asked the Plan to pay for the AAA screening. You say that you only had one ultrasound done for an AAA, 
which is covered once. You also say that there are two claims from two different providers that are billing the 
same current procedural terminology (CPT) code, when you only had the one ultrasound done, and it should be 
covered. The Plan denied your request. The Plan says this claim processed correctly. The Plan also says that 
you have a limit to a one-time screening and have had an abdominal aortic aneurysm screening previously done 
on February 9, 2021. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the AAA screening, and is considered an exception. The contract clearly states 
that a one-time abdominal aortic aneurysm screening is allowed for people at risk. The record shows that you 
received an AAA screening (76706) on February 9, 2021, and your abdominal aortic aneurysm screening 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the abdominal aortic 
aneurysm (AAA) screening (76706) provided on March 16, 2023.  
 
Please Note: The Plan says that they cover one claim from the Professional (physician's service) and one 
Technical (facility and equipment). The Plan further says on the date of service of February 9, 2021, they paid 
a professional claim for an abdominal aortic aneurysm screening. On the date of service of February 9, 2021, 
there is not a technical claim for the same service. Therefore, the Plan was able to cover the technical claim on 
March 16, 2023, but not the professional claim.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99212) provided on April 3, 2023, by a 
chiropractor. 
 
You asked the Plan to pay for the physician service. You say that this was medically necessary. The Plan 
denied your request. The Plan says payment for chiropractor services is limited to treatment by means of 
manual manipulation of the spine to correct a subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99212) provided on April 3, 2023, by a chiropractor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from continued therapy in 
an inpatient rehabilitation setting. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements for admission. Services needed may be provided safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee's records do not show that your continued 
treatments and care can only be given in a hospital setting. When ready to leave the hospital, services can 
safely be received in another setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan.  
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supply allowance for therapeutic continuous glucose monitor 
(CGM) (K0553) provided on October 21, 2022. 
 
You asked the Plan to pay for supply allowance for therapeutic continuous glucose monitor (CGM) (K0553). 
You say that the item 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for supply allowance for 
therapeutic continuous glucose monitor (CGM) (K0553) provided on October 21, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for procedure code J1930 billed for date of service January 6, 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 that the allowed amount for this code is 120. 
 
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 MUE for CPT code J1930 is 120. The MAI value for this code is 3. You billed 120 units of this 
code. Based on this information, we decided that Medicare rules for coverage have been met. Therefore, we 
decided that the Plan has to pay for procedure code J1930 billed for date of service January 6, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on May 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that this is medically necessary. 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 May 3, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the allergy testing identified with codes 86008 and 86003 for date of 
service December 13, 2022. 
 
You asked the Plan to pay for the allergy testing. You say that you required this testing to help identify your 
condition and come up with a plan. The Plan denied your request. The Plan says that the services received are 
not a covered benefit. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided for the allergy testing by a contract provider. The file does not show that the Plan provided 
notice that the allergy testing would not be covered. Under Medicare rules, this means the allergy testing is 
considered approved by the Plan. Therefore, we decided that the Plan has to pay for the allergy testing 
identified with codes 86008 and 86003 for date of service December 13, 2022.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the polycarbonate lenses provided on June 14, 2022. 
 You asked the Plan to pay for the polycarbonate lenses. You say that you knew the insurance was not going to 
pay for the glasses, so you paid over $500 out-of-pocket for glasses. You say the facility is sending a bill for 
$250. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when only covers routine eye exam. 
 
We looked at the file and the Plan's rules. Specifically, the service is not a covered benefit. Based on this 
information, we decided that the Plan's rules for coverage of the polycarbonate lenses have not been met. 
Therefore, we decided that the Plan does not have to pay for the polycarbonate lenses provided on June 14, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an abutment supported to crown (D6064) for tooth #18 
provided on November 9, 2022. 
 
You asked the Plan to pay for the dental service. You say that the procedure is just a crown, and it happens to 
be on the implant post. The Plan denied your request. The Plan says the denial of payment for this service is 
correct, because the abutment supported to crown is not covered by the 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
abutment supported to crown (D6064) for tooth #18 provided on November 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wellness camp. 
 
You asked the Plan to pre-approve the wellness camp. You say that you suffer from obesity and your primary 
doctor offered a referral to a wellness camp or surgery. You say you would like a different approach to weight 
loss.  The Plan denied your request. The Plan says the service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover gym benefits.  
 
The service at issue in this appeal is considered an elective enhancement service. Therefore, we decided that 
the Plan does not have to pre-approve a wellness camp.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stays provided from 
February 4, 2023, to February 16, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stays. You say that the stress from your 
first stay caused you to be readmitted to the hospital. 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 $185 
copayment per day for days 1-7 of each inpatient hospital stay. Your contract with the Plan also clearly says that you then pay a $0 copayment per day for days 8-90 of each inpatient hospital stay. 
 
You have been asked to pay a $185 copayment per day for days 1-7 of the inpatient hospital stay provided from 
February 4, 2023, to February 11, 2023. You have not been asked to pay after day seven or for the day you 
were discharged. You have been asked to pay a total of $1,295 for this inpatient hospital stay ($185 copayment 
per day x 7 days = $1,295). You have also been asked to pay a $185 copayment per day for days 1-2 of the 
inpatient hospital stay provided from February 14, 2023, to February 16, 2023. You have not been asked to pay 
after day two or for the day you were discharged. You have been asked to pay a total of $370 for this inpatient 
hospital stay ($185 copayment per day x 2 days = $370).   
 
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 stays provided from February 4, 2023, to February 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision services provided on February 15, 2023. 
  
You asked the Plan to pay for the vision services. You say that you were new to the Plan and did not know that 
the referral provided by the Plan was only for the office that was indicated on the referral. The Plan denied your 
request. The Plan says the services were not covered benefits. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when received by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, 
we decided that the Plan does not have to pay for the vision services provided on February 15, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the inpatient hospital stay March 31, 2023, 
to April 4, 2023. 
 
You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that you say that you never 
left the emergency room. 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 per day, for days 1 to 5 and a $0 copayment per day, for days 6 to 90 for inpatient care. 
 
 
 You have been asked to pay a $125 copayment per day for days 1 to 5 of the inpatient hospital stay. You have 
been asked to pay a total of $500 ($125 copayment x 4 days = $500). You have not been charged for any 
additional days. 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 reduce the copayment for the inpatient hospital stay March 31, 2023, to April 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99239 billed for date of service February 26, 
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 billed code cannot be verified. 
 
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 99239 is hospital inpatient or observation discharge day 
management; more than 30 minutes on the date of the encounter. We find that CPT code 99239 is not 
supported in the medical record. Specifically, the records do not indicate the amount of time spent with the 
enrollee on the date of service at issue.  Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 99239 billed for date of 
service February 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 3, 2023. 
 
You asked the Plan to pay for the lab services. You say that medical records were provided. The Plan denied 
your request. The Plan says an incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on January 3, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service December 
22, 2022. 
 
You asked the Plan to pay for the billed services. You say that the codes were billed accurately. The Plan 
denied your request. The Plan says the code is not eligible for separate payment. 
 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 93042 is rhythm ECG, 1-3 leads; interpretation and 
report only. We find that CPT code 93042 is not a separately payable service. Therefore, we decided that the 
Plan does not have to pay for procedure code 93042 billed for date of service December 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213 billed for date of service February 14, 
2023. 
 You asked the Plan to pay for the billed services. You say that the incorrect primary diagnosis was used. The 
Plan denied your request. The Plan says a corrected claim may be submitted with an appropriate diagnosis 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 99213 was billed with primary diagnosis code E08.21. There is a code first note 
indicating the underlying condition must be sequenced first. The billed diagnosis is not permitted as the 
primary diagnosis code. Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99213 
billed for date of service February 14, 2023.