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

We decided that the Plan does not have to pay for Transcutaneous Electrical Nerve Stimulator (TENS) supplies billed to the enrollee for October 4, 2022.
You asked the Plan to pay this claim. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and noted that for items that are provided on a recurring basis, suppliers are required to have contact with the beneficiary or caregiver prior to dispensing a new supply of items and there are limitations to the quantity of supplies shipped.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, there is no record of contact with the enrollee prior to shipment and the supplies shipped exceeded the amount allowed by Medicare. Therefore, we decided that the Plan does not have to pay Transcutaneous Electrical Nerve Stimulator (TENS) supplies billed to the enrollee for October 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on May 3, 2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you disagree with the copayment. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for physician/practitioner services/primary care.  
 
You have been asked to pay a $20 copayment for an office visit. This item/service falls within the 
physician/practitioner services/primary 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 an office visit provided on May 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #6. 
 
You asked the Plan to pre-approve the dental service. You say that it is natural to treat your teeth as you age so 
the crown is necessary. The Plan denied your request. The Plan says the denial of authorization for the crown is 
correct, because the x-rays show that there is damage to the tooth because of grinding, abrasion, or acidic oral 
environment. 
 
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 Plan covers the dental 
service when the services are medically necessary and reasonable.  
 
  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 the dental service. Our reviewer says 
that the requested crown does not meet the Plan's coverage criteria. Our physician reviewer found that the 
requested crown on tooth #6 is a optional treatment that may be of long term benefit to the enrollee, though not 
the only method of restoration. The clear attrition from wear is seen on the incisal aspect of the tooth, and there 
is likely little room to lengthen the tooth due to such attrition. A composite restoration would cover the exposed 
dentin and give the surface added strength and be able to fit into the bite properly and would likely be the best 
treatment option in this instance. 
 
The Plan coverage criteria for crowns is when a significant fracture is identified, or when a significant portion 
(50% or more) of the tooth has broken or is missing and has good endodontic, periodontal and/or restorative 
prognoses, and is not required due to wear from attrition, abrasion, abfraction and/or erosion. In this instance 
the radiograph and photo clearly indicate the breakdown is from long-term attrition as seen by the wear patterns 
on the incisal aspect of tooth #6 in the photograph. Given the Plan does not cover crowns in this type of 
situation, the requested crown would not meet the Plan's criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown (D2740) for tooth #6.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure codes 22630, 22840, 63052, and 
22853. We decided that the Plan does not have to pay for the services described by procedure codes 20930 and 
20936.  
 
You asked the Plan to pay for to pay for the surgery services billed for date of service May 24, 2023. You say 
that clinical documentation was provided. The Plan says that no separate payment is made for these services. 
 
We decided that the Plan has to pay for the services described by procedure codes 22630, 22840, 63052, 
and 22853.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure codes 22630, 22840, 63052, and 
22853.  
 
We also decided that the Plan does not have to pay for the services described by procedure codes 20930 
and 20936. 
 
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 codes 20930 and 20936 have a status indicator of B on the Physician Fee Schedule. 
This means that the procedure codes are not separately payable. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the services described by procedure codes 20930 and 20936. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on April 20, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the enrollee was seen for problems with diabetes. 
The Plan denied your request. The Plan says the services are not covered by Medicare. The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for the Outpatient Intravenous Insulin Therapy (OIVIT) services provided on April 20, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99203 billed for date of service April 25, 2023. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was seen by providers of different 
specialties. The Plan denied your request. The Plan says that the enrollee received care within the last three 
years by a provider within the same group practice with the same specialty. 
 
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 code 99203 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and low 
level of medical decision making.  
 
We find that CPT code 99203 is supported in the medical record. The records show that CPT code 99203 was 
billed for a urology visit on the date of service at issue. CPT code 99203 was previously billed on August 23, 
2022, for a visit at the sleep disorder center. The Plan has not provided documentation to show that the enrollee 
received a new patient urology visit within the last 3 years by the same physician or group practice. Based on 
this information, we decided that Medicare rules for coverage of the billed services have been met. Therefore, 
we decided that the Plan has to pay for procedure code 99203 billed for date of service April 25, 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 pre-approve surgical removal of tooth# 5. 
 
You asked the Plan to pre-approve surgical removal of a tooth. You say that this bill should be paid. The Plan 
denied your request. The Plan says the plan does not cover major dental services such as oral surgery, 
periodontics, endodontics, and prosthodontics. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
surgical removal of tooth# 5.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport, 
and ground mileage provided on December 26, 2022. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that the medical records 
support the medical necessity for the ambulance transport. The Plan denied your request. The Plan says the 
claim history shows the enrollee was inpatient from December 19, 2022 to December 30, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that once a beneficiary is admitted to a hospital it may be 
necessary to transport the beneficiary to another hospital or other site temporarily for specialized care while the 
beneficiary maintains inpatient status with the original provider. 
 We looked at the file and Medicare rules. The records provided demonstrate that the enrollee was receiving inpatient 
hospital care at the time of the transport. This means that the transportation service furnished to the enrollee while 
they were admitted as inpatient would be covered as an inpatient hospital and not paid for separately under Part B. 
Based on this information, we decided that Medicare rules for coverage of the ambulance service and ground 
mileage have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, 
basic life support, emergency transport, and ground mileage provided on December 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on June 
09, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you had to make another 
appointment after the provider did not answer your questions during a previous appointment. 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 $50 
copayment for specialist physician/practitioner services. 
 
You have been asked to pay a $50 copayment for the specialist office visit. This item/service falls within the 
specialist physician/practitioner 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 the specialist office visit provided on June 09, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic image (D0330), intraoral-periapical 
radiographic image (D0220, D023), bone replacement graft (D7953), biologic materials to aid in soft and 
osseous tissue regeneration (D3431), retainer crown (D6740) and a pontic (D6245) provided on June 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that this is medically necessary. The Plan denied 
your request. The Plan says your benefit for the panoramic radiographic image and intraoral-periapical 
radiographic images has already been exhausted. The bone replacement graft, biologic materials to aid in soft 
and osseous tissue regeneration, retainer crown and a pontic are not covered services. 
 
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 February 13, 2019. 
Your benefit for the intraoral-periapical radiographic images was exhausted on May 18, 2023. The bone 
replacement graft, biologic materials to aid in soft and osseous tissue regeneration, retainer crown and a pontic 
are not covered services. Therefore, we decided that the Plan does not have to pay for panoramic radiographic 
image (D0330), intraoral-periapical radiographic image (D0220, D023), bone replacement graft (D7953), 
biologic materials to aid in soft and osseous tissue regeneration (D3431), retainer crown (D6740) and a pontic 
(D6245) provided on June 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutment and abutment 
porcelain/metal crown. 
 
You asked the Plan to pre-approve custom fabricated abutment and abutment porcelain/metal crown. You say 
that you believe this is covered. The Plan denied your request. The Plan says implants and related services are 
not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve custom fabricated abutment and abutment porcelain/metal crown.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan 
provided on June 15, 2023. 
 
You asked the Plan to waive the copayment for the computed tomography (CT) scan. You say that it would 
have cost less to go to the emergency room. 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 $225 
copayment for in-network outpatient diagnostic radiology tests. 
 
You have been asked to pay a $225 copayment for the computed tomography (CT) scan. This item/service falls 
within the in-network outpatient diagnostic radiology tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. However, since the allowed amount is less than the 
standard copayment, you only owe $219.34. Therefore, we decided that the Plan does not have to waive the 
copayment for the computed tomography (CT) scan provided on June 15, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided on May 01, 
2023, to May 16, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you believe this should be 
billed as a rehab and stay not a hospital admission. 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 $395 
copayment for inpatient hospital care. 
 
You have been asked to pay a $395 copayment 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 provided on May 01, 2023, to May 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36415 and P9604 billed for date of service 
June 6, 2022. 
 
You asked the Plan to pay for procedure codes 36415 and P9604. You say that these services were necessary 
and are supported as billed. The Plan denied your request. The Plan says these codes are not supported in the 
medical record. 
 
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 procedure codes 36415 and P9604. Our reviewer says that 
these codes are not supported i the medical record. Our reviewer found there is no mention of travelling to 
obtain the specimen venipuncture. It cannot be confirmed that these services were performed as billed. 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 codes 36415 and P9604 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 36415 and P9604 billed for date of service June 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service January 10, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service January 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service May 2, 2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 
is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service May 2, 2023.