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

 
We decided that the Plan does not have to pay for the anesthesia for diagnostic or therapeutic nerve blocks and 
injections (01992) provided on November 9, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the anesthesia services. You say that please review and reconsider reprocessing 
the claim for payment as the Anesthesiologist required the service of a Certified Registered Nurse Anesthetist 
and the provider should be reimbursed for the services. The Plan denied your request. The Plan says enrollees 
must receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered.  
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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item/service at issue. Also, the claim was billed with 
diagnosis codes M54.16 and M46.1, which are not listed under Group 1 codes for diagnosis codes that support 
medical necessity per Local Coverage Article Billing and Coding: Monitored Anesthesia Care A57361. 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 anesthesia for diagnostic or therapeutic nerve blocks and injections (01992) 
provided on November 9, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing. 
 
You asked the Plan to pre-approve genetic testing. You say that you have a family history of cancer. The Plan 
denied your request. The Plan says you do not meet the criteria for the requested testing. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
We looked at the file and the rules. The test at issue in this appeal is being requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pre-approve genetic testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided by an out-of-network provider on August 22, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have provided all the 
required documents and would like the claim processed. 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. Specifically, there is no signed receipt of the delivery. 
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 the supply allowance for a continuous glucose 
monitor (CGM) provided by an out-of-network provider on August 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 3D rendering with interpretation and reporting provided on 
June 01, 2023. 
 
You asked the Plan to pay for 3D rendering with interpretation and reporting. You say that this is supported in 
the records. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 3D rendering with interpretation and reporting provided on June 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on November 9, 2022, billed 
with procedure code 01992-QK. 
 
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 the claim was not billed with the required 
modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that when anesthesia codes are used and MAC has 
been provided, the QS modifier must be used.  
We looked at the file and Medicare rules. The claim has not been reported with the required QS modifier. 
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 November 9, 2022, billed with procedure code 01992-QK.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel provided on July 7, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel 
provided on July 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis - adult (D1110) provided on October 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 2, 2023, and 
June 5, 2023. Therefore, we decided that the Plan does not have to pay for prophylaxis - adult (D1110) 
provided on October 9, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient mental health care provided on 
August 05, 2023, to August 23, 2023. 
 
You asked the Plan to waive the copayment for inpatient mental health care. You say that you are requesting 
reconsideration for the denied claim. 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 $500 
copayment for inpatient services in a psychiatric hospital. 
 
You have been asked to pay a $500 copayment for inpatient mental health care. This item/service falls within 
the inpatient services in a psychiatric hospital 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 mental health care provided on August 05, 2023, to August 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit for evaluation provided on August 14, 2023. 
 
You asked the Plan to pay for the home visit for evaluation. You say that the services 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 home visit for evaluation provided on August 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve personal, disposable or cleansing wipes (E1399). 
 
You asked the Plan to pre-approve wipes. You say that the wipes are medically necessary due to having a 
colostomy bag and every time you attempt to get up or move you need to clean it. The Plan denied your 
request. The Plan says wipes are not generally used primarily for health care, as they are regularly and 
primarily used by persons who do not have a specific medical need for them 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve personal, disposable or cleansing wipes (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a talking thermometer (E1399). 
 
You asked the Plan to pre-approve the talking thermometer. You say that this item is medically necessary. The 
Plan denied your request. The Plan says coverage rules are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the talking thermometer have been met. No medical records were submitted to support the request. There was no physician order for this item. 
Therefore, we decided that the Plan does not have to pre-approve a talking thermometer (E1399).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to reimburse more for anti-reflective coating (V2750), lenses (V2782), and lens 
tinting (V2745) provided on April11, 2023. 
 
You asked the Plan to reimburse more for anti-reflective coating, lenses, and lens tinting. You say that you are 
not disputing the total of $750, you re disputing the fact that you were not credited, discounted, or subtracted 
$400 of the optical insurance discount from the total. The Plan denied your request. The Plan says that this 
benefit has been exhausted. 
 
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 $400 towards the purchase of eyeglasses or contact lenses every year. 
 
We looked at the file and the Plan's rules. The Plan rules say that this Plan covers $400 for eyeglasses or 
contact lenses every year. The Plan contract also says that after Plan paid benefits for eyeglasses (lenses and 
frames) or contact lenses, you are responsible for the remaining cost. The record shows that the Plan is 
supposed to cover $400, with you being responsible for anything over. The record shows that the Plan covered 
$165, which is less than the $400 coverage. The contract does not specify any limitations with regards to the 
eyeglasses, it just states that they cover $400, and the record shows the Plan failed to do that in this situation. 
Based on this information, we decided that the Plan's rules for coverage of anti-reflective coating, lenses, and 
lens tinting have been met. Therefore, we decided that the Plan has to reimburse more for anti-reflective 
coating (V2750), lenses (V2782), and lens tinting (V2745) provided on April11, 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 dental services provided on September 28, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $1,000 annual maximum 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 $1,000 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for dental services provided on September 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (83789-59 and G0480-59) provided 
July 20, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 83789 
is a column II code to column I code 80307. 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. This code is not 
separately reimbursed when billed for specimen validity testing on specimens used for drug testing. Mass 
spectrometry and tandem mass spectrometry is considered inappropriate to bill in addition to drug testing as it 
is inclusive to the service. Furthermore, we have confirmed that code G0480 is a column two code to column 
one code 80307 with a modifier indicator of 0. The column two code is therefore not payable. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (83789-59 and G0480-59) provided July 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for July 24, 2023. 
 
You asked the Plan to pay for diabetic supplies. You say that you have provided all of the appropriate 
documents needed for 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. The proof of delivery provided does not have the 
enrollees signature. 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 July 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral-periapical first radiographic image (D0220) and 
palliative treatment of dental pain (D9110) provided on August 25, 2023 by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that the Plans website shows the provider as in-
network. 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 an intraoral-periapical first radiographic image (D0220) and palliative treatment of dental pain 
(D9110) provided on August 25, 2023 by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the total knee arthroplasty provided on 
September 11, 2023. 
 
You asked the Plan to reduce the copayment for the total knee arthroplasty. You say that your copayment 
should be $325 for inpatient, not $375 for outpatient. 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 $375 
copayment for outpatient hospital services. 
 
You have been asked to pay a $375 copayment for the total knee arthroplasty. This item/service falls within the 
outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for the total 
knee arthroplasty provided on September 11, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 95938TC, 95929TC, 95911TC, 95937TC, 
95885TC and 95940 billed for date of service July 31, 2023. 
 
You asked the Plan to pay for procedure code(s) 95938TC, 95929TC, 95911TC, 95937TC, 95885TC and 
95940. You say that the claim was billed correctly and should be paid. The Plan denied your request. The Plan 
says this code is included in the facility payment and is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 95938TC, 95929TC, 
95911TC, 95937TC and 95885TC. This means there is both a professional and technical component for the 
CPT code(s). In this case, an appropriate modifier to indicate the professional component has not been billed 
with CPT code(s) 95938TC, 95929TC, 95911TC, 95937TC and 95885TC. In addition, we have confirmed that 
code 95940 is an add-on code for code 95938, and the primary code was denied payment. Based on this 
information, we decided that Medicare rules for coverage of procedure code(s) 95938TC, 95929TC, 95911TC, 
95937TC, 95885TC and 95940 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 95938TC, 95929TC, 95911TC, 95937TC, 95885TC and 95940 billed for date of service July 
31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a core build-up (D2950), and a crown 
(D2740) provided on June 14, 2022, to December 9, 2022. 
 
You asked the Plan to waive the coinsurance for D2950 and D2740. You say that you should not have to pay 
for this when work was not even done. 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% 
coinsurance for dental services/non-participating provider.  
 
You have been asked to pay a 50% coinsurance for D2950 and D2740. This item/service falls within the dental 
services/non-participating provider 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 a 
core build-up (D2950), and a crown (D2740) provided on June 14, 2022, to December 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on August 14, 2023. 
 
You asked the Plan to pay for diabetic supplies. You say that you have provided all of the appropriate 
documents needed for 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. The proof of delivery provided does not have the 
enrollees signature. 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 diabetic supplies 
provided on August 14, 2023.