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

 
We decided that the Plan does not have to pay for procedure code 11042 billed for date of service September 7, 
2023.  
 
You asked the Plan to pay for procedure code 11042. You say that the claim is billed correctly and should be 
paid. 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 11042 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 11042 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 11042 billed for date of service September 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for external mobile cardiovascular telemetry 
provided on October 16, 2023. 
 
You asked the Plan to waive the copayment for external mobile cardiovascular telemetry. You say that you 
have never seen this provider. 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 $30 
copayment for each outpatient x-ray, diagnostic procedure & test. 
 
You have been asked to pay a $30 copayment for external mobile cardiovascular telemetry. This item/service 
falls within the each outpatient x-ray, diagnostic procedure & test 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. However the Plan is only holding you responsible 
for a $25.56 copayment. Therefore, we decided that the Plan does not have to waive the copayment for external 
mobile cardiovascular telemetry provided on October 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the power wheelchair (PWC) (K0010) provided 
on September 8, 2023. 
 
You asked the Plan to reimburse you for the PWC. You say that you have submitted 4 claims. You say that one 
paid only $75, one paid $300, and the other two paid nothing. You say that they are all for the same chair and 
provider. You also say that you cannot afford over $300 per month. The Plan denied your request. The Plan 
says the provider in this case is not a Medicare provider. The Plan also says that payment cannot be made for 
items supplied by a provider that is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program.  
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for the power wheelchair (PWC) 
(K0010) provided on September 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on July 28, 2023. 
 
You asked the Plan to pay for diabetic supplies. You say that you have provided all of the appropriate 
documents needed for payment. 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 a valid proof of delivery. The proof of delivery provided does not have the 
enrollees signature. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for diabetic supplies 
provided on July 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the esophagogastroduodenoscopy, flexible, transoral; 
biopsy (43239) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the diagnostic procedure. You say that you need a biopsy and you have 
excruciating pain on your left side. 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 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 Plan has network providers available who are capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 the esophagogastroduodenoscopy, flexible, 
transoral; biopsy (43239) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the onabotulinumtoxina injections, and the 
chemodenervation of a muscle provided on August 31, 2023. 
 
You asked the Plan to waive the cost share for the injections and the chemodenervation of a muscle. You say 
that you disagree with the cost share. 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 Medicare-covered Part B drugs. Your contract with the Plan clearly says that you must pay a 
$35 copayment for each Medicare-covered specialty care visit. 
 
You have been asked to pay $245.08, which is 20% coinsurance of the allowed amount for the injections 
($1,270.40 allowed amount x 20% = $ 245.08). 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.  
 
You have also been asked to pay a $35 copayment for the This item/service falls within the chemodenervation 
of a muscle procedure. This item/service falls 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 cost share for the onabotulinumtoxina 
injections, and the chemodenervation of a muscle provided on August 31, 2023.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for 95938, 95939, and G0453. We decided that the Plan does not have to pay for 95870. 

You asked the Plan to pay for intraoperative testing (procedure codes 95870, 95938, 95939, and G0453) rendered on April 25, 2023. You say that this was medically necessary. The Plan says that this was not medically necessary.

We decided that the Plan has to pay for 95938, 95939, and G0453. 

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

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 for 95938, 95939, and G0453. Our reviewer says that intraoperative neuromonitoring (IONM) (G0453) services are covered for protection of spinal cord where work is performed in close proximity to cord as in the placement or removal of old hardware or where there have been numerous interventions. In this case, the enrollee underwent placement of a spinal cord stimulator. This would meet the definition of placement of hardware in close proximity to the cord (electrode lead placement in particular). Therefore IONM would have been covered for this procedure.

Additionally, somatosensory evoked potentials (SSEP's) (95938 and 95939) are covered for use in intraoperative monitoring. Therefore, this item would be eligible for coverage.

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 item/service at issue have been met. Therefore, we decided that the Plan has to pay for 95938, 95939, and G0453. 

We also decided that the Plan does not have to pay for 95870.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

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 for CPT 95870. Our reviewer says that the records do not demonstrate a covered indication for needle electromyography. It is not eligible for reimbursement.

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 item/service at issue have not been met. Therefore, we decided that the Plan does not have to pay for 95870.

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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the record submitted does not show a 4-week trial with 
a basic pump. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for eye surgery provided on August 14, 2023. 
 
You asked the Plan to waive the copayment for eye surgery. You say that if you were to have known about the 
copayment, you would have had both eyes done. 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 $260 
copayment for outpatient Surgery and Other Medical Services Providedat Hospital Outpatient Facilities and 
Ambulatory SurgicalCenters.  
You have been asked to pay a $260 copayment for eye surgery. This item/service falls within the outpatient 
Surgery and Other Medical Services Providedat Hospital Outpatient Facilities and Ambulatory SurgicalCenters 
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. You 
have been asked to pay a total of $260 copayment for each day of Medicare-covered observation services 
provided to you at an outpatient hospital service. Therefore, we decided that the Plan does not have to waive 
the copayment for eye surgery provided on August 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in-network rate for the detailed and extensive oral evaluation 
(D0160) provided on August 25, 2023. 
 
You asked the Plan to pay the in-network rate for the detailed and extensive oral evaluation. You say that the 
Plan provided a list with this provider's address and phone number on it. You also say that you believed that this provider was in-network. The Plan denied your request. The Plan says this service is not listed as 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 service in this case is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay the in-network rate 
for the detailed and extensive oral evaluation (D0160) provided on August 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), and periapical x-ray 
(D0220) provided on September 13, 2023. 
 
You asked the Plan to pay for the limited oral evaluation and periapical x-ray. You say that you were under the 
impression that the services would be covered. You say that you did not know what was covered under the plan. You also say that the provider did not tell you it would not be covered. The Plan denied your request. The 
Plan says these services are not covered dental services. 
 
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 services in this case are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation (D0140), and periapical x-ray (D0220) provided on September 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abutment supported to a crown (D6058) for tooth 
#12. 
 
You asked the Plan to pre-approve the dental service. You say that the procedure code is incorrect and should 
be a crown and covered by your benefits. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct because the abutment supported to a crown is not covered by the Plan. 
Also, the provider submitted the authorization and therefore needs to submit a new authorization if the code is 
incorrect. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
abutment supported to a crown (D6058) for tooth #12.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a ferric carboxymaltose injection provided 
on August 07, 2023, to August 14, 2023. 
 
You asked the Plan to waive the coinsurance for a ferric carboxymaltose injection. You say that you do not feel 
that you owe anything. 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 Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for a ferric carboxymaltose 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. The total you owe is $378.20 because the Plan is only holding you 
responsible for this amount which is less than the 20% coinsurance. Therefore, we decided that the Plan does 
not have to waive the coinsurance for a ferric carboxymaltose injection provided on August 07, 2023, to 
August 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an epidural injection provided on 
September 11, 2023. 
 
You asked the Plan to waive the copayment for an epidural injection. You say that the procedure was never 
performed. 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 in-network outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers. 
 
You have been asked to pay a $250 copayment for an epidural injection. This item/service falls within the in-network 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 copayment for an epidural injection provided on 
September 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic supplies provided on July 19, 2023. 
 
You asked the Plan to pay for the diabetic supplies. You say that you do not agree with the denial of payment, 
we have sent all the appropriate documents. The Plan denied your request. The Plan says that you are not 
enrolled in Medicare as a durable medical equipment supplier. Therefore, the claim was denied. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the diabetic supplies provided on July 
19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services (S0189 and 11980) provided on 
March 20, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for procedure codes S0189 and 11980. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services received were 
neither emergent nor urgent and prior authorization was not obtained to seek OON care. Additionally, 
procedure code S0189 is invalid for Medicare purposes. 
 
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. Medicare rules also say that providers must report services 
correctly. Providers must report services with the appropriate procedure code. 
 
The Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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. Additionally, we find that procedure code S0189 has a Status 
Indicator of I on the Physician Fee Schedule. This means that procedure code S0189 is not valid for Medicare 
purposes. Therefore, we decided that the Plan does not have to pay for the outpatient services (S0189 and 
11980) provided on March 20, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the diabetic supply allowance provided on 
August 14, 2023. 
 
You asked the Plan to waive the coinsurance for the diabetic supply allowance. You say that you cannot afford 
to pay the billed amount for the items you received. The Plan denied your request. The Plan says only the 
preferred brand products listed in the EOC are covered.  
 The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non-preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the diabetic supply allowance. The total amount allowed to be billed for diabetic supplies provided on 
August 14, 2023, was $708.12. You have been asked to pay an $70.81 coinsurance for the items, which is 10% 
of the total allowed amount. Therefore, we decided that the Plan does not have to waive the coinsurance for the 
diabetic supply allowance provided on August 14, 2023.