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

 
We decided that the Plan does not have to pay for procedure J3490 rendered on March 7, 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 Healthcare Common Procedure Coding System (HCPCS) code J3490-KD 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 J3490 is "Unclassified drugs." 
 
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 medical record includes a 
compounding sheet with mixing medications. In this case, there is a more appropriate code that should be reported for this service documented. J3490 cannot be verified, as no unclassified drugs were found in the 
medical record. 
 
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 J3490 rendered on March 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral comprehensive series of radiographic images 
(D0210) provided on June 2, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 9, 2022. Therefore, 
we decided that the Plan does not have to pay for intraoral comprehensive series of radiographic images 
(D0210) provided on June 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an endosteal implant (D6010) provided on June 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that you needed this dental work. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
  
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 23, 2023. Therefore, 
we decided that the Plan does not have to pay for an endosteal implant (D6010) provided on June 23, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the initial hospital evaluation and management (EM) services provided 
on March 16, 2023, coded as 99223.  
 
You asked the Plan to pay for the EM services. You say that this was billed correctly for necessary care.  The 
Plan denied your request. The Plan says that this code cannot be paid in the place of service (POS) 23, which is 
emergency room.  
 
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's denial rationale is not supported. The rules cited by the 
Plan do not clearly disallow payment for code 99223 when reported in the emergency room POS. Review of 
the record does support that the enrollee was seen by the admitting provider in the emergency room. As such, 
we find no issue with reporting POS 23 for this service.  Therefore, we decided that the Plan has to pay for the 
initial hospital evaluation and management (EM) services provided on March 16, 2023, coded as 99223.   
 
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 pay for procedure code 77387 billed for date of service March 23, 
2023. 
 
You asked the Plan to pay for procedure code 77387. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 77387 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 77387 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 77387 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 77387 billed for date of service March 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87491 and 87798 billed for date of service 
September 30, 2022.  
 
You asked the Plan to pay for codes 87491 and 87798. You say that these services were necessary and are 
supported as billed. The Plan denied your request. The Plan says these codes are not supported in the medical 
record. 
 
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 codes 87491 and 87798 are as follows: 
87491 - Chlamydia trachomatis, amplified probe technique 
87798 - Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified, amplified probe 
technique, per organism probed  
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 codes 87491 and 87798. Our reviewer says that the criteria 
for coverage have not been met. For CPT 87491, our reviewer found that the medical record does not include a 
physician order this test. Also, this procedure was not found in laboratory report, and therefore cannot be 
verified. For CPT 87798, our reviewer found that the laboratory report does not include specific codes reported 
for a "not otherwise specified" procedure code. This procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 87491 and 87798 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 87491 and 87798 billed for date of service September 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-rays billed with codes 73630-RT and 73620-LT provided 
on March 30, 2023. 
 
You asked the Plan to pay for the x-rays. You say that the medical records show that the service performed was 
appropriate with the diagnosis code billed. The Plan denied your request. The Plan says the diagnosis on the 
claim and the laterality modifier on the x-ray codes do not match. 
 
The Plan must follow Medicare rules. Medicare rules say that providers should bill the correct diagnosis that 
points to the side(s) where the condition exists.   
 
In this case, you billed the x-rays in dispute with codes 73630-RT (indicating this occurred on the right side) 
and 73620-LT (indicating this occurred on the left side). For code 73620-LT, you indicated that one of the 
related diagnoses for this service is M77.31, which is for a calcaneal spur of the right foot.  This means that this 
diagnosis is not related to a service performed only on the left foot.  In addition, you billed code 73630-RT with diagnosis code M77.32, which is for a calcaneal spur of the left foot.  This means that this diagnosis is not 
related to a service performed only on the right foot. The diagnosis pointers on the claim are incorrect based on 
the laterality of the diagnoses and the related x-rays. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the x-rays have not been met. Therefore, we decided that the Plan does not have to pay for x-rays 
billed with codes 73630-RT and 73620-LT provided on March 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intermittent limb compression device. 
 
You asked the Plan to pay for an intermittent limb compression device. You say that this device prevents blood 
clots by improving blood flow from the legs to the heart. The goal of this therapy is to prevent or reduce the 
extent of deep vein thromboses in the legs. The Plan denied your request. The Plan says pneumatic 
compression devices are not covered by Medicare for the prevention of venous thromboembolism. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for an intermittent limb compression 
device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
May 1, 2023, to May 4, 2023.  
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were not told that 
you would have a 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 $360 
copayment per day, per admission, days 1-5, for inpatient hospital care. 
 
 You have been asked to pay a $1080 copayment for the inpatient hospital stay ($360 copayment x 3 days = 
$1080). 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 from May 1, 2023, to May 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis -adult (D1110) provided on May 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 24, 2023. 
Therefore, we decided that the Plan does not have to pay for prophylaxis -adult (D1110) provided on May 23, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service and outpatient visit provided on 
February 16, 2023, by an OON provider.  
 
You asked the Plan to pay for the laboratory service and outpatient visit. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says the service was not 
authorized. 
 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. 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 the laboratory service and outpatient visit provided 
on February 16, 2023, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on May 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that this exam was needed to address a lesion on 
your gum. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 12, 2023. 
Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation 
(D0140) provided on May 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for outpatient surgery on March 03, 2023.  
 
You asked the Plan to waive the cost share for outpatient surgery. 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 a $395 
copay, after your $1,000 plan deductible, for each Medicarecovered outpatient surgery at an outpatient 
hospital facility. For the service it's, $1,000 + $395 = $1,395. Therefore, results in the total cost sharing amount 
of $1,395. 
 
You have been asked to pay a $1,395 cost share for outpatient surgery. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 outpatient surgery on March 03, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a complete upper denture (D5110) and a complete 
lower denture (D5120) provided by an out-of-network provider on March 22, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were not aware that the provider was 
an out-of-network provider and the office said they were in-network. The Plan denied your request. The Plan 
says you are responsible for any charged amount above the Plans 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 Plans coverage rules apply in this case. 
 
  The total amount billed for the complete upper denture (D5110) was $1,279 and the total allowed amount was 
$652 leaving a difference of $627 ($1,279 billed - $652 allowed). The total amount billed for the complete 
lower denture (D5120) was $1,279 and the total allowed amount was $652 leaving a difference of $627 ($1,279 
billed - $652 allowed). 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
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 complete upper denture (D5110) and a 
complete lower denture (D5120) provided by an out-of-network provider on March 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network pediatric cardiologist. 
 
You asked the Plan to pre-approve these services. You say that you need to be seen by this provider. The Plan 
denied your request. The Plan says the services are available from network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan confirmed that the in-network 
provider is a tertiary level provider who can provide the same level of care as the requested provider. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the 
Plan does not have to pre-approve a referral to an out-of-network pediatric cardiologist.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for in-network inpatient stays provided 
between March 30, 2023, to May 8, 2023. 
 
You asked the Plan to waive the copayment for in-network inpatient stays. You say that you kept having to be 
in and out of the hospital due to medical complications from a surgery that should have never happened. 
Therefore, you feel you should not need to pay these copayments. 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 $500 
copayment per admission, with an annual out-of-pocket limit of $1,500 for inpatient hospital care.  
 You have been asked to pay a $1,500 total copayment for in-network inpatient stays. 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 
in-network inpatient stays provided between March 30, 2023, to May 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0220 and D0230), a 
crown (D2740) for tooth #4, the bone replacement graft (D4263) for tooth #5 and #11, and an extraction 
(D7210) for tooth #5 and #11 provided by The Wheelchair Store on January 25, 2023, and February 21, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were told that your coverage would 
automatically rollover and you did not need to re-enroll for the year of 2023. The Plan denied your request. The 
Plan says your annual dental maximum benefit for the year has already been exhausted. Also, it was verified 
that the proper information and benefits were given prior the year of 2023. 
 
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 the Plan paid $500 for dental services on January 25, 2023; therefore, your annual dental maximum 
benefit for the year of 2023 was exhausted on the date of service of January 25, 2023. Therefore, we decided 
that the Plan does not have to pay for the intraoral radiographic images (D0220 and D0230), a crown (D2740) 
for tooth #4, the bone replacement graft (D4263) for tooth #5 and #11, and an extraction (D7210) for tooth #5 
and #11 provided by The Wheelchair Store on January 25, 2023, and February 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that this was 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 January 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) for tooth #3 provided on April 10, 
2023. 
 
You asked the Plan to pay for the dental service. You say that you would like the Plan to pay for the service 
because it was medically necessary. The Plan denied your request. The Plan says your benefit for the requested 
item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for a prefabricated post and core (D2954) for tooth #3 on April 10, 2023; therefore, your 
benefit for the requested item or service was exhausted on the date of service of April 10, 2023. Therefore, we 
decided that the Plan does not have to pay for the core buildup (D2950) for tooth #3 provided on April 10, 
2023.