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

 
We decided that the Plan does not have to pay for the office visit (99214) provided on July 26, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the physician service. You say that the service should be covered. The Plan 
denied your request. The Plan says prior authorization was not obtained. 
 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 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 office visit (99214) provided on July 26, 2023, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the dialysis treatment provided on June 
01, 2023, to September 29, 2023. 
 
You asked the Plan to waive the coinsurance for the dialysis treatment. You say that you cannot afford this 
much coinsurance and you are on a fixed income. 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 services to treat kidney disease. 
 
You have been asked to pay 20% coinsurance for the dialysis treatment. This item/service falls within the 
services to treat kidney disease 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 amount you owe is $3,744.58, which is 20% coinsurance of the 
allowed amount for each item. Therefore, we decided that the Plan does not have to waive the coinsurance for 
the dialysis treatment provided on June 01, 2023, to September 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard (D9944) provided on September 20, 2023. 
 
You asked the Plan to pay for an occlusal guard. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
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 an 
occlusal guard (D9944) provided on September 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed for date of service June 27, 
2023. 
 
You asked the Plan to pay for procedure code 99140. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code 99140 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 99140 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99140 billed for date of service June 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental cleaning (D1110) and the periodic oral evaluation 
(D0120) provided on September 5, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. 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 dental services from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the services provided 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 the 
dental cleaning (D1110) and the periodic oral evaluation (D0120) provided on September 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99220 billed for December 28, 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 services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that payment for an initial observation care code is for all 
the care rendered by the ordering physician on the date the patients observation services began. 
 
We looked at the file and Medicare rules. The file shows that an observation code was previously paid for the 
billed date of service. 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 procedure code 99220 billed 
for December 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physicians services provided on August 15, 2023. 
 
You asked the Plan to pay for physicians services. You say that the services were medically necessary. 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 physicians services 
provided on August 15, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan rendered on August 10, 
2023. 
 
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 two of the billed diagnosis codes cannot be reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that R59.9 has an Excludes1 note in relation to R22.1. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for these services have not been met. Therefore, we decided that the Plan does not have to pay for the 
computed tomography (CT) scan rendered on August 10, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the home health services provided from July 
20, 2023, to July 28, 2023. 
 
You asked the Plan to waive the deductible for the home health services. You say that you were told multiple 
times by the home health representatives that you would never see a bill. You also say that you recently 
received a bill for $468.67, and if you had known, you would not have agreed to these services. 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. Your 
contract with the Plan says that there is a $675 deductible which applies to home health agency care.  
 
The item or service you asked the Plan to waive the deductible for falls within the home health agency care 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $675 
deductible which applies to home health agency care. This cost sharing is a contractual obligation that had not 
been met at the time the home health services was received on July 20, 2023 to July 28, 2023. Therefore, we 
decided that the Plan does not have to waive the deductible for the home health services provided from July 20, 
2023, to July 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64454). 
 
You asked the Plan to pre-approve a genicular nerve block. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 to pre-approve a genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient literature to support the safety and efficacy, as defined by 
Medicare rules, of the requested service in your specific clinical scenario. The record provided does not 
establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not recommended. 
 
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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block (64454).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) purchased on  
May 22, 2023. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are only 
covered when purchased from the Plans select hearing aid provider. However, the hearing aids in this case 
were purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5261) purchased on May 22, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for removal of tunneled central venous catheter (36589) 
provided on July 24, 2023. 
 
You asked the Plan to pay for removal of tunneled central venous catheter (36589). You say that the service 
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 removal of tunneled 
central venous catheter (36589) provided on July 24, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0151, G0156, G0299, Q5001) 
provided on March 15, 2023, through March 24, 2023. 
 You asked the Plan to pay for home health services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is March 15, 2023. The NOA was not received by the Plan. As more than 30 
days passed between the timely filing date and the NOA receipt, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for home health services (G0151, G0156, G0299, 
Q5001) provided on March 15, 2023, through March 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on September 
12, 2023. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that for biomarker testing to be covered the 
biomarkers must have proven clinical validity/utility. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. The test does 
not have proven clinical validity/utility. Based on this information, we decided that Medicare rules for coverage 
of the DecisionDx-SCC test have not been met. Therefore, we decided that the Plan does not have to pay for 
the DecisionDx-SCC test (0315U) provided on September 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 04, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. 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 laboratory services 
provided on August 04, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telehealth consultation provided on July 
1, 2023. 
 
You asked the Plan to waive the copayment for the telehealth consultation you received during your hospital 
visit. You say that you should not have to pay a 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 a $75 
copayment for each out-of-network Medicare-covered telehealth visit.  
 
You have been asked to pay a $75 copayment for the telehealth consultation. This service falls within the 
physician/practitioner services, including doctor's 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 consultation 
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 telehealth consultation provided on July 1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nose reconstruction (30410, 99070) provided on May 11, 
2023. 
 
You asked the Plan to pay for nose reconstruction (30410, 99070). You say that you want the Plan to reimburse 
you for the services 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 nose reconstruction 
(30410, 99070) provided on May 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal testing (81479) provided on July 2, 
2023. 
 
You asked the Plan to pay for the Guardant Reveal testing. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests such as the 
Guardant Reveal are subject to the MolDX application, assessment, and approval process.  
 We looked at the file and Medicare rules. We find that the Guardant Reveal test has not been approved for 
coverage based on information in the DEX Diagnostic Exchange. Based on this information, we decided that 
Medicare rules for coverage of the Guardant Reveal testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the Guardant Reveal testing (81479) provided on July 2, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an acute psychiatric inpatient stay 
provided on April 27, 2023, to May 01, 2023. 
 
You asked the Plan to reduce the copayment for an acute psychiatric inpatient stay. You say that this payment 
amount is way too high for the beneficiary to pay. Please consider lowering it or waiving it. 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 $370 
copayment for inpatient services in a psychiatric hospital.  
You have been asked to pay a $370 copayment for an acute psychiatric inpatient stay. This item/service falls 
within the inpatient services in a psychiatric hospital 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 $1,480 for the inpatient 
hospital stay ($370 copayment x 4 days = $1,480). You have not been charged for the day you were 
discharged. Therefore, we decided that the Plan does not have to reduce the copayment for an acute psychiatric 
inpatient stay provided on April 27, 2023, to May 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cardiology visits provided on July 31, 
2022, to August 01, 2022. 
 
You asked the Plan to waive the copayment for cardiology visits. You say that you should not be responsible 
for these copayments, you had been hospitalized and shouldnt pay extra. 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 $40 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for cardiology visits. 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. The total you owe is $80 ($40 x 2 visits = $80). 
Therefore, we decided that the Plan does not have to waive the copayment for cardiology visits provided on 
July 31, 2022, to August 01, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88230, 88271, 88275, 88291) provided on June 
16, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
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 codes 88230, 88271, 88275, & 88291 are not supported in the medical record. Specifically, 
the date of service billed does not match the date of service on the records (June 15, 2023). 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 lab services (88230, 88271, 88275, 88291) provided on June 16, 
2023.