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

 
We decided that the Plan does not have to pay for the psychotherapy sessions and the office visits provided on 
January 13, 2023, through June 16, 2023, by an out-of-network (OON) provider. 
 You asked the Plan to pay for the psychotherapy sessions and the office visits. You say that the services 
provided were essential to prevent readmission. The Plan denied your request. The Plan says the services 
provided were 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 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. The services were not routine dental care. Therefore, we 
decided that the Plan does not have to pay for the psychotherapy sessions and the office visits provided on 
January 13, 2023, through June 16, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that the items should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the items denied correctly as they do not 
meet the clinical requirements to be approved. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for non-adjunctive, non-implanted 
continuous glucose monitor (CGM) device provided July 5, 2023. 
 
You asked the Plan to pay for supply allowance for CGM device. You say that kindly accept your request and 
reprocess your claim. The Plan denied your request. The Plan says the service was provided by a provider that 
is not enrolled in Medicare as a durable medical equipment supplier. 
 
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 supply allowance for non-adjunctive, 
non-implanted continuous glucose monitor (CGM) device provided July 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 provided on August 8, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for procedure code 99214. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide OON care. 
 
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 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. Therefore, we decided that the Plan does not have to pay for 
procedure code 99214 provided on August 8, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S0020 billed for date of service June 15, 
2023. 
 
You asked the Plan to pay for procedure code S0020. You say that S0020 should be paid as billed because it is 
supported in the documentation. The Plan denied your request. The Plan says the billed code is invalid for 
Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that effective for claims with dates of service July 1, 
2007, and after, the non-Outpatient Prospective Payment System (OPPS) Outpatient Code Editor (OCE) will be 
integrated into the OPPS OCE. The rules also say that the Physician Fee Schedule Status Indicator I means that 
this code is not valid for Medicare purposes. 
 
In this case, procedure code S0020 was denied due to I/OCE edit 28, which indicates the code in question is not 
recognized by Medicare for outpatient claims. We find that procedure code S0020 had a Status Indicator of I on 
the Physician Fee Schedule on the date of service billed. This means that procedure code S0020 was not valid 
for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure 
code S0020 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
S0020 billed for date of service June 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service August 25, 2023, billed with code 99153.  

You asked the Plan to pay for procedure code 99153. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says code 99153 is not payable in the facility setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service August 25, 2023, billed 
with code 99153.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a scale attachment for a Hoyer lift. 
 
You asked the Plan to pre-approve these services. You say that the enrollee needs daily weights. The Plan 
denied your request. The Plan says the item 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 a scale attachment for a Hoyer lift.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transport chair (E1038). 
 
You asked the Plan to pre-approve a transport chair (E1038). You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the enrollee has an ultra-lightweight 
wheelchair which serves the same purpose as the requested transport chair. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has an ultra-lightweight wheelchair. An ultra-lightweight wheelchair serves the 
same purpose as a transport chair (E1038). Therefore, we decided that the Plan does not have to pre-approve a 
transport chair (E1038).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93459 billed for date of service April 14, 
2023. 
 
You asked the Plan to pay for procedure code 93459. You say that you are requesting the claim be reviewed 
and reprocessed for payment. The Plan denied your request. The Plan says payment for code 93459 is bundled 
into payment for code 92920. 
 
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 93459 
is a column II code to column I code 92920. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 code 93459 billed for date of service April 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve massage therapy. You say that you would like this provider due to their 
expertise in deep massage therapy and he is willing to come to your house. The Plan denied your request. The 
Plan says the requested services can be provided by 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 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 massage therapy to be provided by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4239 provided on June 27, 2023. 
 
You asked the Plan to pay for procedure code A4239. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the provider is not enrolled in the Medicare 
program. 
 
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 procedure code A4239 provided on June 
27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you an additional amount for the OTC items provided on 
September 24, 2023. 
 
You asked the Plan to reimburse you an additional amount for the OTC items. The Plan denied your request. 
The Plan says you exceeded the $30 balance in the amount of $4.48 when you made the purchase on 
September 24, 2023. 
 
The Plan contract says that the Plan covers a $30 quarterly allowance for eligible over-the-counter (OTC) 
items.  
 
We looked at the file and the Plans rules. The file shows that you exceeded the $30 balance in the amount of 
$4.48 when you made the purchase on September 24, 2023. Therefore, we decided that the Plan does not have 
to reimburse you an additional amount for the OTC items provided on September 24, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse the copayment for the physical therapy on June 26, 2023.  
 
You asked the Plan to reimburse the copayment for the physical therapy. You say that you feel this should be 
reimbursed because this is a long-term knee pain, and you are going through a series of exercises to strengthen 
your knee. 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 each Medicare-covered physical therapy visit.  
 
 
 
 You have been asked to pay a $40 copayment for the physical therapy. This item/service falls within the 
outpatient rehabilitation services 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 reimburse the copayment 
for the physical therapy on June 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry office visit rendered on May 5, 2023. 
 
You asked the Plan to pay for these services. You say that you were having an ingrown toenail issue that was 
not urgent or emergent in nature. The Plan denied your request. The Plan says the services were rendered by an 
out-of-network provider without prior authorization. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
We looked at the file and Medicare rules. The file shows that you received routine foot care that was not urgent 
or emergent in nature. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the podiatry office visit 
rendered on May 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interim complete upper denture (D5810), an interim 
complete lower denture (D5811), and the bone replacement graft (D7953) for tooth #2, #4, #6, #12, #14, #16, 
#18, #20, #22, and #24. 
 
You asked the Plan to pre-approve the dental services. You say that the dental services should be covered with 
no restrictions because they are necessary procedures. The Plan denied your request. The Plan says the denial 
of authorization for these services is correct, because the interim complete upper denture, the interim complete 
lower denture, and the bone replacement graft are not covered by the Plan. 
 
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 pre-approve an 
interim complete upper denture (D5810), an interim complete lower denture (D5811), and the bone 
replacement graft (D7953) for tooth #2, #4, #6, #12, #14, #16, #18, #20, #22, and #24.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the office visit. You say that you are asking for reconsideration. The Plan 
denied your request. The Plan says the Plan does not cover out-of-network services 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 office visit to be provided by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Koya Dayspring non-pneumatic compression system 
(K1033, K1024). 
 
You asked the Plan to pre-approve the Koya Dayspring system. You say that you are requesting an appeal 
regarding the denial of coverage for the enrollee's medical need of the K1024 and K1033 Dayspring active 
compression system and half leg garment. The Plan denied your request. The Plan says neither Medicare nor 
the Plan covers this service. More research is needed to show safety and efficacy of this device. 
 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 Koya Dayspring system have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Koya Dayspring non-pneumatic compression system (K1033, K1024).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant supported, or abutment supported connecting 
bar (D6055). 
 
You asked the Plan to pre-approve implant supported, or abutment supported connecting bar. You say that you 
want a dental implant because you do not like the bridge. You also say the bridge got rotted out and you cannot 
use them because of dry mouth. The Plan denied your request. The Plan says this is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
implant supported, or abutment supported connecting bar (D6055).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite for one anterior surface (D2330), 
resin-based composite for one posterior surface (D2391) and resin-based composite for two posterior surfaces 
(D2392) provided on June 21, 2023. 
 
You asked the Plan to pay for resin-based composite for one anterior surface, resin-based composite for one 
posterior surface and resin-based composite for two posterior surfaces. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for resin-
based composite for one anterior surface (D2330), resin-based composite for one posterior surface (D2391) and 
resin-based composite for two posterior surfaces (D2392) provided on June 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for over-the-counter COVID-19 test kits provided on September 
1, 2023. 
 
You asked the Plan to pay for over-the-counter COVID-19 test kits. You say that you have a Medicare 
Advantage. You also have Medicare Part A and B coverage. The Plan denied your request. The Plan says this 
is not a covered benefit. 
 
  The rules say that Medicare does not pay for OTC items and over-the-counter COVID-19 test kits is an OTC 
item. The Plan does not offer coverage for OTC items, which includes COVID-19 test kits. Therefore, we 
decided that the Plan does not have to pay for over-the-counter COVID-19 test kits provided on September 1, 
2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan 
provided on September 05, 2023. 
 
You asked the Plan to waive the copayment for the computed tomography (CT) scan. You say that you do not 
think you should have to pay the copayment for the service you received. 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 $200 
copayment for diagnostic radiology services, such as ultrasound, nuclear cardiac imaging, PET, MRI, and CT 
scan.  
You have been asked to pay a $200 copayment for the computed tomography (CT) scan. This item/service falls 
within the diagnostic radiology services, such as ultrasound, nuclear cardiac imaging, PET, MRI, and CT scan 
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, since the allowed amount is less than the standard copayment, you only owe $125.95. Therefore, we 
decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan provided 
on September 05, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a chest x-ray provided on August 03, 2023. 
 
You asked the Plan to waive the copayment for a chest x-ray. You say that this should not have 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 $90 
copayment for outpatient hospital services. 
 
You have been asked to pay a $90 copayment for a chest x-ray. This item/service falls within the outpatient 
hospital services 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 chest x-ray 
provided on August 03, 2023.