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

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service  
September 10, 2023, to September 23, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that this service was medically necessary. 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 providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service September 10, 2023, to September 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral device/appliance used to reduce upper airway 
collapsibility (E0486) provided on July 19, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were not aware this oral device was not a 
covered benefit. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services 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 oral device/appliance used to reduce upper airway collapsibility (E0486) provided on July 19, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and chiropractic manipulative treatment 
provided on August 24, 2023, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and chiropractic manipulative treatment. You say that  The Plan 
denied your request. The Plan says the office visit and chiropractic manipulative treatment are available in 
network.  
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit and chiropractic manipulative 
treatment provided on August 24, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298) purchased on 
October 10, 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 the hearing aids in this case 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 (V5298) purchased on October 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for maxillary partial denture (D5211) 
provided on August 16, 2023. 
 
You asked the Plan to waive the coinsurance for maxillary partial denture (D5211). You say that the provider 
ordered a partial that would cover the entire upper part of the inside of your mouth without ever consulting you. 
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 50% 
coinsurance for maxillary or mandibular partial denture  resin base.  
 
 You have been asked to pay 50% coinsurance for maxillary partial denture (D5211). This item/service falls 
within the maxillary or mandibular partial denture  resin base benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for maxillary partial denture (D5211) provided on August 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home or residence visit for the evaluation provided on July 
13, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for a home or residence visit for the evaluation. You say that the services should be 
covered. The Plan denied your request. The Plan says this was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a home or residence visit for the evaluation 
provided on July 13, 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 a Group 3 standard power wheelchair with multiple 
power options (K0861) and additional items and accessories (codes E1007, E2311, E1012, E2361 x2, E1028, 
E2377, E0955, E1028, E2313, E2607, and E2620). 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair and additional items and accessories. 
You say that you have attached Medicare's approval along with justification for the wheelchair found in the 
clinical documentation. The Plan denied your request. The Plan says the patient does not have medical need for 
multiple power options included with a K0861 Group 3 power wheelchair. The Plan also says the electronic 
connection, expandable controller harness, and expandable controller cannot be covered as it is not medically 
necessary to control the three requested power options through the joystick (drive interface). 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with multiple 
power options (such as code K0861) is covered if the criteria listed in the Medicare rules section of this letter 
are met. Medicare rules also say that if the PWC base is not covered, then related accessories will be denied. 
 
 
  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 Group 3 standard power wheelchair 
and additional items and accessories. Our reviewer says that the criteria for coverage have not been met. Our 
physician reviewer found the provided records from the prescribing physician do not support that the patient is 
high risk for skin breakdown and is unable to perform a functional weight shift (they walk short distances with 
a wheeled walker), has a history of pressure ulcer(s) or has had skin flap surgery. Records do not document the 
patient performs bladder self-catheterization and is unable to transfer independently or that the patient has 
increased muscle tone or spasticity to meet criteria for the power tilt and/or recline and thus the multiple power 
option base. Our reviewer also found that as the requested wheelchair base does not meet Medicare coverage 
criteria, the requested accessories are not covered.  
 
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 Group 3 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 standard power 
wheelchair with multiple power options (K0861) and additional items and accessories (codes E1007, E2311, 
E1012, E2361 x2, E1028, E2377, E0955, E1028, E2313, E2607, and E2620).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64450-59 provided on August 4, 2023. 
 
You asked the Plan to pay for procedure code 64450-59. You say that the medical records support the billing of 
procedure code 64450-59 as a distinct or independent service from other services performed on the same day. The Plan denied your request. The Plan says the medical records do not support the billing of procedure code 
64450-59 as a distinct or independent service from other services performed on the same day. 
 
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 64450 is a column II code to column I code 01470; however, 64450 
was billed with a modifier.  
 
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 procedure code 64450-59. Our reviewer says that the medical 
records do not support the billing of procedure code 64450-59 as a distinct or independent service from other 
services performed on the same day. Our reviewer found the provider reported procedure code with appended 
modifier 59 to bypass NCCI Edit with anesthesia service provided on same date of service. The procedure 
report documents "ANESTHESIA SUMMARY; Anesthesia: General; Regional; L popliteal Nerve Block".  In 
this case, medical record includes insufficient documentation to support injection was given for post op pain 
management at the request of the surgeon, as well as documentation to support anesthesia was not dependent 
on the injection performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 64450-59 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 64450-59 provided on August 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing codes 80050, 80061, 83540, 83550, and 83036 
provided on June 16, 2023. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says appropriate 
diagnosis codes were not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. We find that CPT code 80050 is not a covered Medicare test. We find that 
CPT codes 80061, 83540, 83550, and 83036 were billed with diagnosis codes that are not covered for the 
testing at issue. Medical records were not provided to show that the testing was ordered for a covered medical 
indication. Based on this information, we decided that Medicare rules for coverage of the services provided 
have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing codes 80050, 
80061, 83540, 83550, and 83036 provided on June 16, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency ambulance services provided on  
July 17, 2023, by an OON provider.  
 
You asked the Plan to pay for non-emergency ambulance services. You say that you are requesting a 
retroactive authorization. The Plan denied your request. The Plan says prior authorization is required for non-
emergency ambulance services provided by an OON 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 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 non-emergency ambulance services provided on 
July 17, 2023, by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
services received on August 9, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
the enrollee was not the one that called 911 and should not be responsible for the bill. The Plan denied your 
request. The Plan says without transport there are no payable services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 9, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without 
transport services received on August 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care. provided on August 02, 
2023. 
 
You asked the Plan to pay for subsequent nursing facility care.. You say that you would like reconsideration 
based on the records submitted. 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 subsequent nursing 
facility care. provided on August 02, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care. provided on July 21, 2023, to July 25, 
2023. 
 
You asked the Plan to pay for nursing facility care.. You say that the services rendered 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 nursing facility care. 
provided on July 21, 2023, to July 25, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on October 18, 2023. 
 You asked the Plan to pay for the ambulance services. You say that the enrollee was not on hospice at the time 
of service. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on October 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and associated services provided on August 7, 
2023. 
 
You asked the Plan to pay for the office visit and associated services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the provider has opted out of 
the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office 
visit and associated services provided on August 7, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the procedure has not been scheduled 
yet.  The Plan denied your request. The Plan says a CardioMEMS device is not medically necessary. 
 
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 CardioMEMS device. Our reviewer 
says that a CardioMEMS device is not medically necessary.  Our physician reviewer found a CardioMEMS is 
still considered an investigational device and may not benefit the enrollee.  
 
  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 CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve duplex scans of extracranial arteries (codes 93880 and 
93882). 
 
You asked the Plan to pre-approve duplex scans of extracranial arteries. You say that this test was ordered to 
determine if there is any need to change the patient's current management. The Plan denied your request. The 
Plan says the enrollee does not meet the medical necessity criteria for the requested ultrasound of both sides of 
head and neck blood flow. 
 
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 duplex scans of extracranial arteries. 
Our physician reviewer found the patient has a medical history of carotid stenosis as shown on ultrasound in 
August 2022, showing an estimated 20 to 39% stenosis of the right and left internal carotid arteries. A request 
for pre-approval for repeat ultrasound, duplex scans of extracranial arteries (93880 and 93882) was made to 
monitor this condition. Our reviewer also found that the severity of stenosis was not high enough to warrant a 
procedure or change in treatment at the time of the previous testing, therefore, repeat testing this soon after the 
prior ultrasound is not reasonable or medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of duplex scans of extracranial arteries have not been met. Therefore, we decided 
that the Plan does not have to pre-approve duplex scans of extracranial arteries (codes 93880 and 93882).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxycodone. 
 
You asked the Plan to pre-approve Oxycodone. You say that the medication is medically necessary for 
enrollees treatment for post laminectomy syndrome. The Plan denied your request. The Plan says the 
medication is not covered as a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Oxycodone.  
 
Benefits for Oxycodone may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.