Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code E0484 provided on April 27, 2023. 
 
You asked the Plan to pay for procedure code E0484. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as 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 find that CPT code E0484 is not supported in the medical record. Specifically, this code has no 
professional component and is not listed on the Physician Fee Schedule. Based on this information, we decided 
that Medicare rules for coverage of procedure code E0484 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code E0484 provided on April 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on October 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were not aware the provider was out-of-
network prior to the appointment. 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 periodic oral evaluation (D0120) and prophylaxis (D1110) provided on October 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on August 22, 2023, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient hospital services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 
when received by an out-of-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 a POS option to use either network providers or out-of-network providers for certain 
covered services. The Plan contract also says that out-of-network outpatient surgery and other medical services 
provided at hospital outpatient facilities and ambulatory surgical centers are not covered. 
 
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 this service. Therefore, we 
decided that the Plan does not have to pay for the outpatient hospital services provided on August 22, 2023, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for porcelain and ceramic crown (D2740) and core buildup 
(D2950) provided on September 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were not informed that the provider would 
no longer accept your Plan. 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 January 18, 2023. 
Therefore, we decided that the Plan does not have to pay for porcelain and ceramic crown (D2740) and core 
buildup (D2950) provided on September 18, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on August 17, 2023, to 
September 1, 2023. 
 
You asked the Plan to pay for home health services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says the facility must be enrolled to participate 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 home health services provided on 
August 17, 2023, to September 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code E1390 provided on August 18, 2023. 
 
You asked the Plan to pay for procedure code E1390. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the documentation requirements have not been 
met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case with a date of service of August 18, 2023. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for procedure code 
E1390 provided on August 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal medicament carrier-for the upper arch 
(D5995) and the periodontal medicament carrier-for the lower arch (D5996) provided on February 10, 2023. 
 
You asked the Plan to pay 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 covered under the supplemental 
dental policy.  
 
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 items provided are not among those 
covered under this benefit.  
  
 
Therefore, we decided that the Plan does not have to pay for the periodontal medicament carrier-for the upper 
arch (D5995) and the periodontal medicament carrier-for the lower arch (D5996) provided on February 10, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic supplies provided on August 24, 2023. 
 
You asked the Plan to pay for the diabetic supplies. You say that you are requesting reconsideration stating you 
have submitted all the relevant documents, including proof of delivery and other supporting documents to 
fulfill your obligations. The Plan denied your request. The Plan says you are not enrolled in Medicare as a 
durable medical equipment supplier. Therefore, the claim remains denied. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the diabetic supplies provided on August 
24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal guard-hard appliance, full arch (D9944) 
provided on August 30, 2023. 
 
You asked the Plan to pay for this dental item. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the item provided 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 item provided was exhausted on date of service March 29, 2021.  
  
 
Specifically, the Plans contract states that an occlusal guard is covered once every 36 months. You previously 
received this dental item on March 29, 2021, less than 36 months prior, which was paid for by the Plan. 
Therefore, you have exhausted the allowable benefit for this dental item. Therefore, we decided that the Plan 
does not have to pay for the occlusal guard-hard appliance, full arch (D9944) provided on August 30, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from July 21, 2023, through 
July 24, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient hospital care provided 
was not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the enrollee was admitted to the Intensive Care Unit (ICU) and treated with 3 liters of intravenous 
fluids and on pressors. The enrollees vital signs then normalized. The computed tomographic angiography 
(CTA) of the left femur was performed which revealed a patent graft. The computed tomography (CT) of the 
abdomen and pelvis revealed moderate or severe stenosis of the bilateral internal iliac, celiac/mesenteric, and 
renal arteries. The urinalysis showed evidence of a possible urinary tract infection (UTI) with red blood cell 
and white blood cell counts elevated. The enrollee was downgraded from the ICU and treatment for possible 
sepsis was continued with a presumed UTI source. The enrollee improved and was discharged with 
recommendations for a follow up and a prescription for Ciprofloxacin given the concern for a UTI. The review 
has determined that the record showed that at the time of the inpatient admission it was reasonable for the 
admitting physician to expect that the enrollees necessary hospital care (including earlier emergency 
department (ED) and/or observation care) would span two midnights with supporting documentation of the 
enrollees history and comorbidities, signs and symptoms, current medical needs, and risk of an adverse event. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from July 21, 2023, through July 24, 2023.  
 
 
  
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review.  
 
The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we 
decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on  
October 18, 2023. 
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 
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 service provided was exhausted on date of service February 2, 2023.  
  
 
Specifically, the Plans contract states that one oral evaluation (D0120-D0180) is covered per calendar year.  
You previously received a comprehensive oral evaluation (D0150) on February 2, 2023, less than one year 
prior, which was paid for by the Plan. Therefore, you have exhausted the allowable benefit for this service. 
Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on 
October 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental cleaning (D1110) and the periodic oral 
evaluation (D0120) provided on August 3, 2023. 
 
You asked the Plan to pay more 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 you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider.  
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the dental cleaning (D1110) and the periodic 
oral evaluation (D0120) provided on August 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring 
described by code G0453 performed on date of service October 30, 2023. 
 
You asked the Plan to pay for G0453. You say that G0453 should be paid as billed because it is supported in 
the medical record and was medically necessary. The Plan denied your request. The Plan says G0453 is denied 
because it was billed with diagnosis codes that do not support medical necessity.  
 
The Plan must follow Medicare rules. Medicare rules say that M47.892, M48.02, and M54.12 are not listed as 
diagnosis codes that support medical necessity when billed G0453. 
 
We looked at the file and Medicare rules. In this case we confirmed that G0453 was billed with a total of three 
diagnosis codes. These are M47.892 (other spondylosis, cervical region), M48.02 (spinal stenosis, cervical 
region) and M54.12 (radiculopathy, cervical region). No other diagnoses were listed on the claim. Per LCA A57604, diagnosis codes M47.892, M48.02, and M54.12 do not support medical necessity when billing G0453. 
As such the denial of G0453 is appropriate. Based on this information, we decided that Medicare rules for 
coverage of G0453 have not been met. Therefore, we decided that the Plan does not have to pay for the 
continuous intraoperative neurophysiology monitoring described by code G0453 performed on date of service 
October 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom-fabricated abutment (D6057 x2) and abutment 
supported porcelain/ceramic crowns (D6058 x2) provided on September 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that you experienced severe pain in your mouth due 
to a gum infection. You say your doctor feels the dental procedures performed was out of a medical necessity 
and not simply cosmetic. 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 the Plan has paid the $1,000 annual maximum. Therefore, we decided that the Plan does not have to pay 
for the custom-fabricated abutment (D6057 x2) and abutment supported porcelain/ceramic crowns (D6058 x2) 
provided on September 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic supplies provided on August 3, 2023. 
 
You asked the Plan to pay for the diabetic supplies. You say that you are requesting reconsideration of payment 
for services rendered. The Plan denied your request. The Plan says you are not enrolled in Medicare as a 
durable medical equipment supplier. Therefore, the claim remains denied. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the diabetic supplies provided on August 
3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on August 15, 2023. 
 
You asked the Plan to pay for the refraction. You say that refractions are covered by your insurance. You say 
you had your yearly eye exam and should not be responsible for the $40. The Plan denied your request. The 
Plan says the refraction is not a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when received during a routine eye examination. 
 
We looked at the file and the Plan's rules. Specifically, the refraction was provided during a medical eye 
examination. The record shows you were seen for a cataract evaluation, which is medical in nature. Based on 
this information, we decided that the Plan's rules for coverage of the refraction have not been met. Therefore, 
we decided that the Plan does not have to pay for the refraction provided on August 15, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93976 billed for date of service October 25, 
2023. 
 You asked the Plan to pay for procedure code 93976. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 93976 is bundled into payment for code 
76856. 
 
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 93976 
is a column II code to column I code 76856. 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 93976 billed for date of service October 25, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on July 20, 2023, billed with 
procedure codes 99215 and G2212. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. 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 E83.51 has an Excludes1 note in relation to E21.1. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the practitioner services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for practitioner services provided on July 20, 2023, billed with procedure codes 99215 and G2212.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a breast ultrasound and a breast biopsy 
provided from October 5, 2023, to October 9, 2023. 
 
You asked the Plan to waive the copayments for an ultrasound and biopsy. You say that you cannot afford 
these copayments on your restricted 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 a $100 
copayment for outpatient diagnostic tests and therapeutic services and supplies, and a $370 copayment for 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $470 total copayment for an ultrasound and biopsy. This item/service falls within 
the outpatient diagnostic tests and therapeutic services and supplies and outpatient surgery, including services 
provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayments for a breast ultrasound and a breast biopsy provided from October 5, 
2023, to October 9, 2023.