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

 
We decided that the Plan does not have to pay for procedure code 99233 for date of service February 13, 2023. 
 
You asked the Plan to pay for procedure code 99233. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99233 is subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded. 
 
We find that CPT code 99233 is not supported in the medical record. Specifically, the documentation did not 
include the time spent on this service. A time of 50 minutes or more must be documented in the medical 
records. Based on this information, we decided that Medicare rules for coverage of procedure code 99233 have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99233 for date of 
service February 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 13, 2023. 
 
You asked the Plan to pay for the lab services. You say that the treatment sought was medically necessary. The 
Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 

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 February 13, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 25 additional home health skilled nursing visits (G0299 
x25). 
 
You asked the Plan to pre-approve the additional home health skilled nursing visits. You say that you believe 
the enrollee will benefit from registered nurse visits, as they will assist with changed the enrollee's catheter, 
thus preventing infection and other health risks. The Plan denied your request. The Plan says the services are 
not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 25 additional home health skilled 
nursing visits. Our reviewer says that the requested home health services are not medically necessary. Our 
physician reviewer found the documentation does not support that the enrollee requires additional skilled 
nursing services to provide treatment that is medically necessary. The enrollee does not require additional 
skilled nursing services to effectively provide treatment, care, and/or services in order to improve their 
condition, perform a maintenance program to maintain their condition and/or prevent deterioration. Our 
reviewer also found that the enrollee has been medically stable without any recent exacerbations of chronic 
medical problems or hospitalizations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 25 additional home health skilled nursing visits have not been met. Therefore, 
we decided that the Plan does not have to pre-approve 25 additional home health skilled nursing visits (G0299 
x25).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided on May 11, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the inpatient services. You say that the facility is responsible for authorization 
for all of their patients. 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 inpatient services provided on May 11, 2023, 
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 17, 
2023. 

You asked the Plan to pay for procedure code 99100. You say that you are an anesthesia provider, so you are 
covered under the surgeon's authorization. The Plan denied your request. The Plan says procedure code 99100 
is considered bundled and not separately payable.  
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service April 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87500, 87653, 87481, and 87798 
billed for date of service December 12, 2022. 
 
You asked the Plan to pay for procedure codes 87150, 87500, 87653, 87481, and 87798. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says payment for code 87150, 87500, 
87653, and 87798 cannot be made as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 87150 
is a column II code to column I code 87500. We have confirmed that code 87641 is a column II code to column 
I codes 87801 and 87150. We have confirmed that code 87653 is a column II code to column I codes 87801 
and 87150. We have confirmed that code 87798 is a column II code to column I codes 87801 and 87150. We 
have confirmed that code 87481 is a column II code to column I codes 87801 and 87481. This claim has not 
been billed with an appropriate modifier to bypass the edit. Code 87500 is not supported in the documentation. 
Specifically, the medical records submitted do not include a physician order or laboratory requisition for the 
billed test. 
 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 87150, 87500, 87653, 87481, and 87798 billed for date of service 
December 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  additional power wheelchair accessories (E2311, 
E2313, E2377). 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that this is medically 
necessary.  The Plan denied your request. The Plan says there is no medical need to control the power options 
through the joystick.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the durable medical equipment (DME). 
Our physician reviewer found the requested electrical accessories are not medically necessary as the member 
does have use of the upper extremity and can operate and control the power options using the switches that are 
included in the basic wheelchair. There is not a medical need for the upgraded electronics. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve  additional power wheelchair accessories (E2311, E2313, 
E2377).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network diagnostic 
radiopharmaceutical injection provided on April 14, 2023. 
 
You asked the Plan to waive the coinsurance for an in-network diagnostic radiopharmaceutical injection. You 
say that you were not told there would be a secondary charge and do not understand why you are being charged 
so much. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
The allowed amount of this drug is $5,527.89, resulting in a coinsurance amount of $1,105.58 ($5,527.89 x 
20% = $1,105.58). You have been asked to pay a $1,105.58 coinsurance for an in-network diagnostic radiopharmaceutical 
injection. This item/service falls within the Medicare Part B prescription 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. Therefore, we decided that the Plan 
does not have to waive the coinsurance for an in-network diagnostic radiopharmaceutical injection provided on 
April 14, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a panoramic radiographic image (D0330) provided on May 25, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says that your benefit for the requested item or service 
has already been exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pay for a panoramic radiographic image (D0330) 
provided on May 25, 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 a complete denture - maxillary (D5110) and complete 
denture - mandibular (D5120) provided on April 10, 2023. 
 
You asked the Plan to pay for the complete dentures. You say that the Plan's representative never stated the 
service was not in-network. 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 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 a 
complete denture - maxillary (D5110) and complete denture - mandibular (D5120) provided on April 10, 2023.  
 
Your complaint about your dissatisfaction with being placed on hold for thirty minutes and not being told the 
provider was not in-network is not a valid appeal for medical coverage. This part of your complaint is a 
grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types 
of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic CGM and monthly supplies for one year to 
be provided by an OON provider.  
 
You asked the Plan to pre-approve a therapeutic CGM and monthly supplies for one year. You say that you do 
not agree with the denial of the requested CGM and supplies. The Plan denied your request. The Plan says the 
service can be provided by an in-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 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. 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 therapeutic CGM and monthly supplies for one year to be provided by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a hammertoe correction procedure provided 
on March 16, 2023. 
 
You asked the Plan to waive the copayment for a hammertoe correction procedure. You say that you disagree 
with the 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 $250 
copayment for outpatient surgery, including services provided at ambulatory surgical center. 
 
You have been asked to pay a $250 copayment for a hammertoe correction procedure. This item/service falls 
within the outpatient surgery, including services provided at ambulatory surgical center 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 a hammertoe correction procedure provided on March 16, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on April 26, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. 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 the office visit provided 
on April 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visits provided by an in-network 
provider from May 19, 2022, to February 2, 2023. 
 
You asked the Plan to waive the copayment for the office visits. You say that you are seeing this provider as a 
primary care physician. 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 $45 
copayment for in-network physician specialist services in 2022, and a $40 copayment for in-network 
Medicarecovered physician specialist services in 2023. 
 You have been asked to pay a $90 copayment for the office visits provided on May 19, 2022, and October 6, 
2022 ($45 copayment x 2 visits = $90). You have also been asked to pay a $40 copayment for the office visit 
provided on February 2, 2023. These items/services fall within the physician/practitioner services, including 
doctors office visits 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 office visits 
provided by an in-network provider from May 19, 2022, to February 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on May 3, 2023, by an out-of-
network provider. 
 
You asked the Plan to pay more for the dental services. You say that you were surprised when you got a bill for 
this much. 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. 
 
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 dental services provided on May 3, 2023, by 
an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a device evaluation provided on March 04, 2023. 
 
You asked the Plan to pay for a device evaluation. You say that you are requesting reconsideration of the 
denied claim. 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 a device evaluation 
provided on March 04, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 20, 2022, billed with 
codes 81225, 81227, 81230, 81231,81232, 81306, 81328, 81355, 81335, 0031U, 0032U, and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
July 20, 2022, billed with codes 81225, 81227, 81230, 81231,81232, 81306, 81328, 81355, 81335, 0031U, 
0032U, and 0033U.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on April 
20, 2023. 
 
You asked the Plan to pay for the dental services. You say that you stated to the technician that you had pain in 
the upper and lower jaws related to the teeth. 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 August 26, 2021. 
Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided 
on April 20, 2023.