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

 
We decided that the Plan does not have to pay for the monitoring feature/device billed with code A9279 for 
date of service September 16, 2023. 
 
You asked the Plan to pay for code A9279. You say that an extension was given for timeliness of claims filing. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that claims with code A9279 will be denied as 
statutorily non-covered.  Neither Medicare nor the Plan covers this item. Therefore, we decided that the Plan 
does not have to pay for the monitoring feature/device billed with code A9279 for date of service September 
16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 17, 2023. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary, please review records 
and reprocess. 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 an office visit provided 
on August 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on September 10, 2023. 
 
You asked the Plan to pay for the drug testing. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the drug testing 
provided on September 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), intraoral-
comprehensive series of radiographic images (D0210), upper partial denture (D5213), and the lower partial 
denture (D5214) provided on August 17, 2023. 
 
You asked the Plan to pay for the dental items/services. 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 items/services 
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 items/services provided has already been exhausted. Specifically, the Plans contract 
states that one full mouth x-ray is covered every five calendar years. The record shows that you previously 
received this service on February 18, 2021, less than five years prior, which was paid for by the Plan. The 
Plans contract also states that one comprehensive oral evaluation is covered every three calendar years. You 
previously received this service on February 18, 2021, less than three years prior, which was paid for by the 
Plan. Additionally, the Plans contract states that one lower and/or one upper partial denture is covered every 
five calendar years. You previously received an upper partial denture and a lower partial denture on April 7, 
2021, less than five years prior, which were paid for by the Plan. Therefore, you have exhausted the allowable 
benefit for the items/services provided in this case. Therefore, we decided that the Plan does not have to pay for 
the comprehensive oral evaluation (D0150), intraoral-comprehensive series of radiographic images (D0210), 
upper partial denture (D5213), and the lower partial denture (D5214) provided on August 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing (83789) provided on July 25, 2023. 
 
You asked the Plan to pay for validity testing. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing.  

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of validity testing have not been met. Specifically, we find that the testing described by the billed 
code is considered specimen validity testing which is not separately payable. Therefore, we decided that the 
Plan does not have to pay for validity testing (83789) provided on July 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code E2394 billed for date of service May 12, 
2023.  
 You asked the Plan to pay for procedure code E2394. You say that you billed two units of this code because 
you billed both the left and right sides. The Plan denied your request. The Plan says the number of units billed 
exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code E2394 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code E2394 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code E2394 billed for date of 
service May 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown, core buildup, and post and core in addition to 
crown (D2740, D2950, D2952) provided on August 24, 2023, to September 15, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the denial. 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 September 1, 2023. 
Therefore, we decided that the Plan does not have to pay more for a crown, core buildup, and post and core in 
addition to crown (D2740, D2950, D2952) provided on August 24, 2023, to September 15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral waterjet ablation of the prostate (0421T). 
 
You asked the Plan to pre-approve transurethral waterjet ablation of the prostate. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that treatment for lower urinary tract symptoms/benign 
prostatic hyperplasia (LUTS/BPH) treatment will be considered reasonable and necessary when certain criteria 
are met. 
 
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 transurethral waterjet ablation of the 
prostate. Our reviewer says that the services are not medically necessary. Our physician reviewer found based 
on the medical records provided there is no documentation that the transurethral waterjet ablation of the 
prostate at issue in this case meets all criteria detailed in the LCD L38549. Provided records in this case do not 
document a prostate volume of 30-150 cc [cubic centimeters] by transrectal ultrasound (TRUS) as required by 
the LCD; records document a prostate volume of 223 cc by magnetic resonance imaging. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transurethral waterjet ablation of the prostate have not been met. Therefore, we 
decided that the Plan does not have to pre-approve transurethral waterjet ablation of the prostate (0421T).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total hip replacement. 
 You asked the Plan to pre-approve a total hip replacement. The Plan denied your request. The Plan says a total 
hip replacement 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 total hip replacement. Our reviewer 
says that a total hip replacement is not medically necessary. Our physician reviewer found that the 
documentation is not evident regarding malignancy of the joint involving the bones, soft tissues of the pelvis, 
proximal femur, avascular necrosis, fracture of the femoral neck, acetabular fracture, non-union, failure of 
previous hip fracture surgery, mal union of acetabular, or proximal femur fracture. Additionally, the provided 
x-rays of the bilateral hips did not demonstrate advanced joint disease. Moreover, there is no indication of a 
trial and failure of formal physical therapy. Therefore, the enrollee does not meet the LCD coverage criteria. 
 
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 total hip replacement have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total hip replacement.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 28, 2023. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 28, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from August 14, 2023, to  
September 18, 2023. 
 
You asked the Plan to pay for psychotherapy. You say that these services were previously covered. The Plan 
denied your request. The Plan says the service was provided by a non-covered provider type. 
 
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 psychotherapy provided from  
August 14, 2023, to September 18, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 7, 2023 to July 
18, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA was filed timely. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA. Based on this information, we find that the Medicare rules for payment 
of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for the home 
health services provided from July 7, 2023 to July 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on January 30, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered.  
 
We looked at the file and Medicare rules. The service at issue is non-covered.  Therefore, we decided that the 
Plan does not have to pay for the Cxbladder test (0012M) provided on January 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653, 87798, and 
87801 provided on October 12, 2023. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87641, 87653, 87798, and 87801. 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 as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653, 87798, and 87801 provided on 
October 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided October 3, 2023, billed with 
codes 87500-59, 87641-59, 87798 x13, G0452-26, 87491-59, 87496-59, 87529-59, 87532-59, 87563-59, 
87591-59, 87481- 59, 87651-59, 87653-59. 
 
You asked the Plan to pay for the laboratory testing. You say that you do not personally see patients and are 
dependent on receiving patient information from the ordering provider. The Plan denied your request. The Plan 
says panel testing should be billed using one Current Procedural Terminology (CPT) code on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory testing provided October 3, 2023, billed with codes 87500-59, 
87641-59, 87798 x13, G0452-26, 87491-59, 87496-59, 87529-59, 87532-59, 87563-59, 87591-59, 87481- 59, 
87651-59, 87653-59.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional intraoral x-ray and fillings (D0220, D2335 x2) 
provided on August 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for intraoral x-rays has already been 
exhausted. The cost-sharing for the fillings applied correctly based on the services provided. 
 
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 intraoral x-rays was exhausted on the appealed claim with date of service August 3, 
2023 (D0220). 
 
You have been asked to pay a $50 copayment for 2 dental fillings on teeth #22 and #11.  This item/service falls 
within the dental 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 pay for an additional intraoral x-ray 
and fillings (D0220, D2335 x2) provided on August 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Proteus wound care panel provided on August 8, 2023, 
and billed with codes 87481, 87500, 87640, 87641, 87651, 87653, and 87798. 
 
You asked the Plan to pay for the Proteus wound care panel. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.   
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the Proteus wound care panel provided on August 8, 2023, and billed with codes 
87481, 87500, 87640, 87641, 87651, 87653, and 87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychology services provided on July 20, 2023. 
 
You asked the Plan to pay for psychology services. You say that you are requesting reconsideration for the 
denied claim. 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 psychology services 
provided on July 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 5, 2023, billed with 
procedure codes 11056 and 11721-59. 
 
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 this claim has not been billed with the required 
modifier. 
 
The Plan must follow Medicare rules. The rules say that all claims for routine foot care based on the presence 
of a systemic condition should have a billing indicator of Q7, Q8 or Q9 to be considered for payment.  
 
This claim has not been billed with the required indicator to be considered for payment. Based on this 
information, we decided that Medicare rules for coverage of the practitioner services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for practitioner services provided on May 5, 
2023, billed with procedure codes 11056 and 11721-59.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the filling for a crown with posts (D2950) on tooth #31, 
#8, #9, the all-white glass crown (D2740) on tooth #8, #31, #9. 
 
You asked the Plan to pre-approve the filling for a crown with posts (D2950) on tooth #31, #8, #9, the all-white 
glass crown (D2740) on tooth #8, #31, #9. You say that crowns are covered under your Plan. You say you want 
the Plan to pay for the services. The Plan denied your request. The Plan says the services are not covered 
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. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the filling for a crown with posts 
(D2950) on tooth #31, #8, #9, the all-white glass crown (D2740) on tooth #8, #31, #9 are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the filling for a 
crown with posts (D2950) on tooth #31, #8, #9, the all-white glass crown (D2740) on tooth #8, #31, #9.