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

 
We decided that the Plan does not have to pay for the inpatient evaluation and management (EM) services 
provided on August 15, 2022, billed with code 99223. 
 
You asked the Plan to pay for the EM services. You say that the claim should be paid as billed. The Plan 
denied your request. The Plan says current procedural terminology (CPT) 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 99223 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 EM services. Our physician says that the documentation 
does not support procedure code 99223.  Our reviewer found the history of present illness and past history are 
not comprehensive, though it is noted that the member and family were poor historians.  The physical 
examination is not comprehensive.  As such, the billing of CPT 99223 is not supported.  
 
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 EM services have not been met. Therefore, we decided that the Plan does 
not have to pay for the inpatient evaluation and management (EM) services provided on August 15, 2022, 
billed with code 99223.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 19, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the genetic testing. You say that the molecular testing was requested directly 
form the treating physician who makes professional determination of diagnosis and medical necessity to 
successfully treat the enrollee. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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 genetic testing provided on October 19, 2022, 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Partially Favorable

 
You asked the Plan to pay for surgical services (43281, 43235) provided on June 9, 2022. You say that the 
services were medically necessary. The Plan says that the documentation does not support the billed services. 
 
We decided that the Plan has to pay for code 43281.  
 
The operative report provided supports that this procedure was performed. Therefore, we decided that the Plan 
has to pay for code 43281.  
 
We also decided that the Plan does not have to pay for code 43235. 
 The file does not show that an esophagogastroduodenscopy was performed. Therefore, we decided that the Plan 
does not have to pay for code 43235. 
 
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 coinsurance for the tildrakizumab injection provided on 
February 09, 2023. 
 
You asked the Plan to waive the coinsurance for the tildrakizumab injection. You say that you cannot find the 
part of your contract that explains the coinsurance amount for this service. 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 in-network Medicare Part B drugs. 
 
You have been asked to pay 20% coinsurance for the tildrakizumab injection. This item/service falls within the 
in-network Medicare Part B drugs 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 $2,785.60 ($13,928 allowed amount x 20% coinsurance = 
$2,785.60). Therefore, we decided that the Plan does not have to waive the coinsurance for the tildrakizumab 
injection provided on February 09, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for scaling in presence of generalized moderate or server 
gingival inflammation (D4346) provided on December 9, 2022. 
 
 
You asked the Plan to pay for scaling in presence of generalized moderate or server gingival inflammation. 
You say that this should be covered. The Plan denied your request. The Plan says this is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for scaling in 
presence of generalized moderate or server gingival inflammation (D4346) provided on December 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation  new or established patient 
(D0150) provided on December 8, 2022. 
 
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 February 22, 2021. 
Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation  new or 
established patient (D0150) provided on December 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a magnetic resonance imaging (MRI) provided on November 
18, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an MRI. You say that this was medically necessary. The Plan denied your 
request. The Plan says this 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 a magnetic resonance imaging (MRI) provided on 
November 18, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited exam to evaluate a problem (D0140), panoramic 
radiographic image (D0330) and therapeutic parenteral drug, single administration (D9610) provided on 
October 14, 2022, to December 16, 2022. 
 
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 items or services 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 limited exam was exhausted on date of service September 7, 2022, and the benefit 
for the panoramic radiographic image was exhausted on October 18, 2022. Therefore, we decided that the Plan 
does not have to pay for limited exam to evaluate a problem (D0140), panoramic radiographic image (D0330) 
and therapeutic parenteral drug, single administration (D9610) provided on October 14, 2022, to December 16, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the polycarbonate lens, the progressive lens, the anti-
reflective coating, the tint, the prism lens, the bifocal sphere, and the frames provided on December 28, 2022. 
 You asked the Plan to pay for the vision items. You say that you are entitled to a $100 reimbursement. The 
Plan denied your request. The Plan says the vision services are excluded from coverage under your plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for the polycarbonate lens, the progressive lens, the anti-reflective 
coating, the tint, the prism lens, the bifocal sphere, and the frames provided on December 28, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on December 19, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the patient was under the value-based 
insurance design (VBID) benefit plan and the medical records provided support the need for the ambulance 
transport. The Plan denied your request. The Plan says the enrollee was enrolled in hospice services on this 
date of service. Therefore, traditional Medicare is the primary payer for this date of service. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on December 19, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance services 
provided on December 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat lift mechanism and chair. 
 You asked the Plan to pre-approve a power seat lift mechanism and chair. You say that the requested item is 
medically necessary. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. The rules also say that Medicare will pay for durable medical 
equipment that is mainly used to serve a medical purpose. 
 
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 a power seat lift mechanism. Our 
reviewer says that the coverage criteria has not been met. Our physician reviewer found that you have 
osteoarthritis of the knee joints. However, the in-home occupational therapy evaluation indicated that you are 
independent with transfers from a low recliner. You are modified independent with the assistance of a Rollator 
for mobility throughout your home. Therefore, the requested power seat lift mechanism is not medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power seat lift mechanism have not been met. A power seat chair is 
considered a convenience item and does not service a medical purpose. Therefore, we decided that the Plan 
does not have to pre-approve a power seat lift mechanism and chair.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on December 31, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you did 
not use the ambulance and do not think you should be responsible for paying for it. 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 Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 31, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on December 31, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from August 16, 2022, to 
September 2, 2022. 
 
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 was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that where required by law or regulation, report the Federal 
Information Processing Standards (FIPS) State and County Code of the place of residence where the home 
health service is delivered with code 85. 
 
 
 
 We looked at the file and Medicare rules. The file shows that the claim was not billed with the proper FIPS 
code. 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 home health services rendered from 
August 16, 2022, to September 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service May 28, 
2022. 
 
You asked the Plan to pay for procedure code 0003A. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service May 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain fused to predominantly base metal 
tooth #'s 6, 7 and 8 (D2751). 
 
You asked the Plan to pre-approve the crown restorations. You say that this is a medical necessity and there is 
currently 50% or more bone in support around the tooth and no active periodontal disease. The Plan denied 
your request. The Plan says the x-rays sent show a crown is not needed to fix your tooth. 
 
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 Plan covers the crown 
restorations when the services are medically necessary and reasonable.  
 
 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 crown restorations. Our reviewer 
says that approval for the requested service could not be made. Our physician reviewer found due to the lack of 
proper documentation (poor radiographs) the criteria for coverage and the need for crown restorations for teeth 
#'s 6, 7, and 8 could not be made. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown restorations have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a crown - porcelain fused to predominantly base metal tooth #'s 6, 7 and 8 
(D2751).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on July 18, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you had a 
head injury and was not competent to sign anything. You also say that you didn't go to the hospital. 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 Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 18, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on July 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on July 20, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for chiropractic care. You say that this is supported in the records. The Plan denied 
your request. The Plan says this 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 chiropractic care provided on July 20, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on September 20, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for podiatry services. You say that this is supported in the records. The Plan denied 
your request. The Plan says this 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 podiatry services provided on September 20, 2022, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that this is medically necessary. The 
Plan denied your request. The Plan says the requirements for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Freestyle Libre 2 continuous glucose monitor (CGM) and 
supplies. 
 
You asked the Plan to pay for a CGM and supplies. You say that a CGM is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the medical criteria for a CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does use insulin with at 
least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM 
and supplies have not been met. Therefore, we decided that the Plan does not have to pay for a Freestyle Libre 
2 continuous glucose monitor (CGM) and supplies.