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

 
We decided that the Plan does not have to pay for procedure code 99285 provided on September 19, 2022. 
 
You asked the Plan to pay for procedure code 99285. You say that the medical records support the billing of 
code 99285 provided on September 19, 2022. The Plan denied your request. The Plan says the medical records 
do not support the billing of code 99285 provided on September 19, 2022. 
 
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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: 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 presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function. 
 
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 procedure code 99285. Our reviewer says that the medical 
records do not support the billing of code 99285 provided on September 19, 2022. Our reviewer found the 
review has determined that the medical records supported a comprehensive history and a comprehensive 
examination, however, medical decision making of high complexity was 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 procedure code 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285 provided on September 19, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lower extremity prosthesis, not otherwise specified, 
heavy duty endoskeletal system for patients over 250 pounds (L5999). 
 
You asked the Plan to pre-approve the prosthetic feature. You say that you would like to appeal the denial for 
lack of medical necessity. The Plan denied your request. The Plan says the features are already included with 
the approved prosthesis and cannot be requested separately. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the prosthetic feature have not been met. Therefore, we decided that the Plan does not have to pre-
approve the lower extremity prosthesis, not otherwise specified, heavy duty endoskeletal system for patients 
over 250 pounds (L5999).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical each additional radiographic image 
(D0230), core buildup, including any pins when required (D2950) x3 and pontic - porcelain fused to high noble 
metal (D6240) x5 and does not have to pay more for retainer crown - porcelain fused to high noble metal 
(D6750) x1 and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including 
elevation of mucoperiosteal flap if indicated (D7210) x3 provided on September 13, 2022, and November 29, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you have insurance so you should not have such 
a large out of pocket responsibility. 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. This benefit includes the 
requested D0230 but is limited to one procedure code per calendar year. D2950 and D6240 are not covered 
under the Plans dental benefit. This benefit includes an annual maximum of $2,000 for covered dental 
benefits. 
 
We looked at the file, the Plans rules, and Medicares rules. You previously received covered intraoral - 
periapical first radiographic image (D0220) on September 13, 2022. Therefore, this benefit has been exhausted 
as of September 13, 2022. Although these are two different services, they fall within the same category in your 
Evidence of Coverage and are subject to the same frequency limitations. Therefore, we decided that the Plan 
does not have to pay for intraoral - periapical each additional radiographic image (D0230) provided on 
September 13, 2022, and November 29, 2022. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D2950 and D6240 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for core 
buildup, including any pins when required (D2950) x3, pontic - porcelain fused to high noble metal (D6240) x5 
provided on September 13, 2022, and November 29, 2022. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid $1,907 on September 13, 2022, and $93 on November 29, 2022 ($1,907 + $93 = $2,000). 
After the annual maximum is exhausted, any remaining charges are your responsibility. Therefore, this benefit 
has been exhausted. Therefore, we decided that the Plan does not have to pay for retainer crown - porcelain 
fused to high noble metal (D6750) x 1 and extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) x3 provided on 
September 13, 2022, and November 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient psychotherapy services rendered on June 14, 
2022. 
 
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 the services were no documented and billed as incident to physicians professional services with 
documentation of direct supervision of the physician. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 90834 is not supported in the medical record. Specifically, this service was provided by 
a social worker. This rendering provider is not eligible to furnish this service. 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 outpatient psychotherapy services rendered on June 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray guidance services provided on September 19, 2022, to 
September 21, 2022. 
 
You asked the Plan to pay for x-ray guidance services. You say that this is supported in the records. 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 x-ray guidance services 
provided on September 19, 2022, to September 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services provided on May 2, 2022. 
 
You asked the Plan to pay for the podiatry services. You say that you are asking for reconsideration of the 
denied claim. The Plan denied your request. The Plan says that Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the podiatry services provided on May 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 19, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing.
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 9, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing.
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
November 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power seat elevation feature (E2300). 
 
You asked the Plan to pre-approve the power seat elevation feature. You say that your current power 
wheelchair is completely worn out and needs to be replaced. The Plan denied your request. The Plan says that a 
power seat elevation feature does not serve a medical purpose and is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve the power seat elevation feature (E2300).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy services provided from April 1, 
2022, to May 31, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home infusion therapy services. You say that the services billed are 
supported in the records. The Plan denied your request. The Plan says enrollees must receive their care from a 
network provider. 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 home infusion therapy services provided from 
April 1, 2022, to May 31, 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 additional units of procedure code 99222 billed for date of 
service January 24, 2022. 
 
You asked the Plan to pay for procedure code 99222. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 99222 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. The documentation does not show that the excess units were provided, correctly 
coded, and medically necessary. Based on this information, we decided that Medicare rules for coverage have 
not been met. Therefore, we decided that the Plan does not have to pay for additional units of procedure code 
99222 billed for date of service January 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 21, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing.
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 21, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient pain management services provided on 
October 24, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the pain management services. You say that you have been seeing the pain specialist for four years. You were informed that you can still get services from the doctor. The Plan denied your request. The Plan says enrollee's 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 outpatient pain management services provided 
on October 24, 2022, by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rituxan. 

You asked the Plan to pre-approve Rituxan. The Plan denied your request. The Plan says there is no indication 
that you have tried and failed the required drugs. Our reviewer also found that based on the medical records 
provided and the Medicare-approved major drug compendia there is no indication that the Plan's required drugs 
would likely be less effective and/or likely have adverse effects for the enrollee. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Rituxan. Our reviewer says that you do not meet the coverage criteria for Rituxan. Our physician reviewer found there is no indication that you have tried and failed the required drugs. Our reviewer also found that there is no indication that the Plan's required drugs would likely be less effective and/or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Rituxan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Rituxan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that the requested item is medically 
necessary. The Plan denied your request. The Plan says this item not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for special stain including interpretation provided on January 13, 
2023. 
 
You asked the Plan to pay for special stain including interpretation. You say that the services 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 special stain including 
interpretation provided on January 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye scan provided on December 22, 
2022. 
 
You asked the Plan to waive the copayment for the eye scan. You say that you already paid 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 $10 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $10 copayment for the eye scan. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for the eye scan provided on December 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from November 19, 2022, 
to November 21, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA was submitted. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA as required. Based on this information, we find that the Medicare rules for 
payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for 
the home health services provided from November 19, 2022, to November 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A7048 billed for dates of service July 27, 
2022, to August 10, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the 
documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  The record does not contain valid proof of delivery, for the supplies at issue in this case. Based on this 
information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code A7048 billed for dates of service July 27, 2022, to August 10, 
2022.