Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that this item is medically necessary. 
The Plan denied your request. The Plan says this item is not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0675 to treat peripheral arterial disease 
is not eligible for reimbursement. 
 
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, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 83520 and 87798 rendered on February 20, 
2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain 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. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the reported codes have a 
definition with "not otherwise specified." However, the records do not have documentation of the specific 
procedures being reported with these codes; therefore, the codes cannot be verified.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 83520 and 87798 rendered on February 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4221, A4222, A4305 rendered from 
January 27, 2023, to February 2, 2023. 
 
You asked the Plan to pay for the services. You say that all of the supplies were medically necessary. The Plan 
denied your request. The Plan says the supply codes do not include a valid proof of delivery. 
 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 asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that although the medical records do 
contain a patient-signed delivery ticket for the codes billed, a signed physician order for these services was not 
provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes A4221, A4222, A4305 rendered from January 27, 2023, to February 2, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF visit provided from December 6, 
2022, to December 31, 2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you feel you should not be 
responsible for the cost share applied. 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 $0 
copayment for days 1 to 20, a $150 copayment per day for days 21 to 44, and $0 copayment for days 45 to 100 
for SNF care.  
 You have been asked to pay a $900 copayment for a SNF stay ($150 per day x 6 days = $900). This 
item/service falls within the SNF care 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 
SNF visit provided from December 6, 2022, to December 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam CT capture and interpretation, limited (D0364) 
provided on June 7, 2023. 
 
You asked the Plan to pay for cone beam CT capture and interpretation, limited. 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 cone 
beam CT capture and interpretation, limited (D0364) provided on June 7, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on May 31, 2023, to 
June 03, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you were in the ER under 
observation and don't feel you should be responsible. 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 a day copayment for days 1-5 for inpatient hospital care. Includes inpatient acute, inpatient 
rehabilitation, long-term care hospitals and other types of inpatient hospital services. Inpatient hospital care 
starts the day you are formally admitted to the hospital with a doctors order. The day before you are 
discharged is your last inpatient day. There were three days. 3 x $370 = $1,110. Therefore, results in the total 
cost shairng amount of $1,110. 
 
You have been asked to pay a $370 copayment a day for inpatient hospital stay. This item/service falls within 
the inpatient hospital care 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 inpatient 
hospital stay on May 31, 2023, to June 03, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic imaging (D0330) and a limited oral evaluation 
(D0140) provided on June 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 February 8, 2021, and 
May 1, 2023. Therefore, we decided that the Plan does not have to pay for panoramic imaging (D0330) and a 
limited oral evaluation (D0140) provided on June 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for additional routine transportation mileage. 
 
You asked the Plan to provide coverage for additional routine transportation mileage. You say that you need 
transportation to your provider's office that is more than 50 miles away. The Plan denied your request. The Plan 
says the request of 91 miles exceeds the benefit limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case.  
 
We looked at your request, the records in the case file, and the rules. The file shows that the Plans 
transportation benefit provides coverage for up to 48 one-way trips, combined in and out-of-network, are 
covered each year. Each one-way trip must not exceed 50 miles of driving distance. The request of 91 miles 
exceeds the benefit limit. Based on this information, we decided that the Plans rules for coverage of routine 
transportation have not been met. Therefore, we decided that the Plan does not have to provide coverage for 
additional routine transportation mileage.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a ForeseeHome Age-Related Macular Degeneration 
Monitoring program. 
 
You asked the Plan to pay for a ForeseeHome Age-Related Macular Degeneration Monitoring program. You 
say that the test was medically necessary in determining the best course of treatment. The Plan denied your 
request. The Plan says this is non-covered due to being investigational/experimental. 
 
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 pay for a ForeseeHome Age-Related Macular 
Degeneration Monitoring program. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the ForeseeHome Age-Related 
Macular Degeneration Monitoring program is still being studied to detect changes in vision with macular 
degeneration. Our physician reviewer also found that it is currently experimental and investigational. 
Therefore, the ForeseeHome Age-Related Macular Degeneration Monitoring program  has not been shown to 
be at least as beneficial as existing and available standard medical practice for the monitoring of this patient's 
condition. 
 
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 ForeseeHome Age-Related Macular Degeneration Monitoring program have 
not been met. Therefore, we decided that the Plan does not have to pay for a ForeseeHome Age-Related 
Macular Degeneration Monitoring program.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for full mouth debridement to enable a comprehensive 
evaluation and diagnosis (D4355) provided on May 30, 2023. 
 
You asked the Plan to pay for full mouth debridement to enable a comprehensive evaluation and diagnosis. 
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 full 
mouth debridement to enable a comprehensive evaluation and diagnosis (D4355) provided on May 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment provided on August 
5, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the chiropractic manipulative treatment. You say that this is supported in the 
records. The Plan denied your request. The Plan says enrollees must receive their care from a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the item/service 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 this item/service. Therefore, 
we decided that the Plan does not have to pay for the chiropractic manipulative treatment provided on August 
5, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mobile x-ray services provided on March 14, 2023. 
 
You asked the Plan to pay for the mobile x-ray services. You say that these services were medically necessary 
and should not be considered incidental to any other service. The Plan denied your request. The Plan says you 
billed an incorrect Place of Service code on the claim. The place of service 11 was billed, however, 
documentation received does not support the services were performed in an office or other outpatient setting 
but rather in a mobile setting at a skilled nursing facility (SNF). There is a more appropriate place of 
service code (POS 15). 
 
The Plan must follow Medicare rules. Medicare rules say that when services are furnished in a mobile unit, 
they are often provided to serve an entity for which another Place of Service (POS) code exists. In those cases, 
providers should use the POS code for that entity. However, if the mobile unit is not serving an entity which could be described by an existing POS code, the providers are to use the Mobile Unit POS code 15. 
 
In this case, you billed POS code 11 (which indicates an office setting).  These mobile x-ray services did not 
occur in an office setting, but rather in a mobile unit in the parking lot of a skilled nursing facility.  As a result, 
this claim should have been billed with either the SNF POS (31) or the mobile unit POS (15). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the mobile x-ray services have not been met. Therefore, we decided that the Plan does not have to 
pay for mobile x-ray services provided on March 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, and 87798 rendered on 
February 7, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain 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 the denied codes is: 
 
CPT 87481: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe technique 
 CPT 87653: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique 
 
CPT 87798: 
 
Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, 
each organism 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the laboratory report does not 
include enough documentation to support using modifier XU - unusual non-overlapping service. The denied 
codes and the modifier cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 87481, 87653, and 87798 rendered on February 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral hygiene instructions (D1330) and panoramic 
radiographic image (D0330) provided on April 26, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 panoramic radiographic image was exhausted on date of service April 26, 2023. 
Therefore, we decided that the Plan does not have to pay for oral hygiene instructions (D1330) and panoramic 
radiographic image (D0330) provided on April 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for excision of benign lesion (D7410) provided on April 26, 
2023. 
 
You asked the Plan to pay for excision of benign lesion. 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 excision 
of benign lesion (D7410) provided on April 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services provided on March 29, 2023, billed 
with codes 99204, 92611, 74230, 72040, 70100, 70310, 71045, and 74240. 
 
You asked the Plan to pay for the services as billed. You say that these services were medically necessary and 
should be paid.  The Plan denied your request. The Plan says the POS code reported is not valid.  
 
The Plan must follow Medicare rules. Medicare rules say that for mobile radiology services the POS code 
should either be that of the setting in which the enrollee was seen or the mobile POS code 15.  
 
We looked at the file and Medicare rules. The records show that the enrollee was in home health. The POS 
code billed was 11 for office setting. There is no evidence that the services were performed at a doctor's office. 
Based on this information, we decided that Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the radiology services provided on March 29, 
2023, billed with codes 99204, 92611, 74230, 72040, 70100, 70310, 71045, and 74240.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network inpatient hospital stay 
provided from November 19, 2022, to November 25, 2022. 
 
You asked the Plan to waive the copayment for an in-network inpatient hospital stay. You say that you cannot 
afford this copayment and need it to be waived. 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 per day, for days 1-6 for inpatient hospital services.  
 
You were in the hospital for 7 days, resulting in a $1,500 total copayment ($250 x 6 days = $1,500). 
 You have been asked to pay a $1,500 total copayment for an in-network inpatient hospital stay. This 
item/service falls within the inpatient 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 an in-network inpatient hospital stay provided from November 19, 2022, to November 25, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services you received from a Licensed Marriage and 
Family Therapist (LMFT) on February 8, 2023. 
 
You asked the Plan to pay for the LMFT services. You say that this therapist is the only one qualified to work 
with you who was in alignment with your personal values. The Plan denied your request. The Plan says you 
went to a provider who is not eligible to perform these services under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that that the only provider types eligible to provide 
Medicare-covered mental health services are as follows: Physicians, Clinical Psychologists, Clinical Social 
Workers, Clinical Nurse Specialists, Nurse Practitioners, Physician Assistants, Certified Nurse-Midwives, 
Independently Practicing Psychologists, and Certified Registered Nurse Anesthetists.  
 
The provider you saw is a LMFT.  LMFTs are not eligible for coverage under Medicare rules. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the LMFT services have not been met. Therefore, we decided that the Plan does not have to pay for 
therapy services you received from a Licensed Marriage and Family Therapist (LMFT) on February 8, 2023.