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

 
We decided that the Plan does not have to waive the cost share for an office visit provided on January 30, 2023. 
 
You asked the Plan to waive the cost share for an office visit. You say that you disagree with the cost share. 
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. Your 
contract with the Plan says that there is a $226 deductible which applies to physician/practitioner services.  
 
The item or service you asked the Plan to waive the cost share for falls within the physician/practitioner 
services benefit category. You are being asked to pay $85.93 towards your $226 deductible. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $226 deductible which applies to 
physician/practitioner services. This cost sharing is a contractual obligation that had not been met at the time an 
office visit was received on January 30, 2023. Therefore, we decided that the Plan does not have to waive the 
cost share for an office visit provided on January 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on May 22, 2023.  
You asked the Plan to pay for the refraction. You say that  the reimbursement is paid to you since the provider 
was out-of-network. You say that the refraction is a part of the provider's exam, and the refraction was itemized 
separately from the "Comprehensive Services" code. 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 the refraction when it is received as a part of a routine eye examination. 
 
We looked at the file and the Plan's rules. Specifically, the refraction was provided during a medical eye exam. 
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 May 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen equipment purchased on January 18, 2023. 
 
You asked the Plan to pay for the oxygen equipment. You say that the item should be covered. The Plan denied 
your request. The Plan says the purchased oxygen equipment is not a covered benefit. 
 
The Plan follows Medicare rules. Medicare rules state that purchased oxygen equipment is statutorily non-
covered. 
 
In this case, the oxygen equipment at issue was purchased and not rented. Neither Medicare nor the Plan covers 
purchased oxygen equipment. Therefore, we decided that the Plan does not have to pay for oxygen equipment 
purchased on January 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for date of service May 18, 
2023. 
 
You asked the Plan to pay for the billed code. You say that this is a valid procedure code. The Plan denied your 
request. The Plan says code 99153 is not payable in the facility setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 We find that payment for CPT code 99153 is not supported. The claim shows that the services were provided in 
an outpatient hospital facility setting. There is no separate payment to the physician for CPT code 99153 when 
performed in the facility setting. Therefore, we decided that the Plan does not have to pay for procedure code 
99153 billed for date of service May 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lens fitting provided on March 1, 2023.  
You asked the Plan to pay for the contact lens fitting. You say that you were told you were covered up to $100 
and then told the coverage was $250. The Plan denied your request. The Plan says the service 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 only covers one routine eye exam and up to $100 for eyeglasses or contact lenses every two 
years. 
 
We looked at the file and the Plan's rules. Specifically, the contact lens fitting is not a covered benefit. Based 
on this information, we decided that the Plan's rules for coverage of the contact lens fitting have not been met. 
Therefore, we decided that the Plan does not have to pay for the contact lens fitting provided on March 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on June 
5, 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 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 April 12, 2019. 
Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided 
on June 5, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room (ER) visit (0202U, 80053, 84484) 
provided on June 24, 2023. 
 
You asked the Plan to pay for the ER visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as the rendering provider 
is not enrolled with Medicare. 
 
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 an emergency room (ER) visit (0202U, 
80053, 84484) provided on June 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Ultraviolet (UV) Light therapy system (E0691), provided 
on May 22, 2032. 
 
You asked the Plan to pay for the UV light therapy system. You say that the item was medically necessary. The 
Plan denied your request. The Plan says there is no documentation that a face-to-face encounter took place 
between this enrollee and the ordering provider as it pertains to psoriasis and the need for the Ultraviolet Light 
therapy system 
 
The Plan must follow Medicare rules. Medicare rules say that UV light therapy systems are covered for 
selected patients with generalized intractable psoriasis. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the UV light therapy system have not been met. Therefore, we decided that the Plan does not have 
to pay for the Ultraviolet (UV) Light therapy system (E0691), provided on May 22, 2032.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on June 1, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you 
required emergency medical service as you went into insulin shock due to your glucose levels dropping. You 
also say that upon speaking to a doctor, he said since you were already treated you did not need to go to the 
emergency room. The Plan denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 1, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on June 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99152 billed for date of service April 27, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the documentation supports the services billed. 
The Plan denied your request. The Plan says the billed code cannot be verified. 
 
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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status. We find that CPT code 99152 is not supported in the medical record. Specifically, the records do not document 
the presence of an independent trained observer to monitor the level of consciousness. 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 procedure code 99152 billed for date of service April 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 11, 2022. 
 
You asked the Plan to pay for the lab services. You say that the documentation supports the necessity of the 
panel. The Plan denied your request. The Plan says an incorrect place of service code was billed. 
 
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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. The claim was billed with multiple codes. The 
panel test was not billed with a single code as required. Based on this information, we decided that Medicare 
rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to 
pay for the lab services provided on February 11, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation miles. 
 
You asked the Plan to pre-approve the additional miles. You say that you are 80 years old and live alone and 
have no one to provide this transportation. The Plan denied your request. The Plan says your benefit only 
allows routine transportation up to 50 miles one-way. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 miles one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. You are requesting a trip of 72 miles. 
Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of 
routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation miles.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 11, 2022, 
to December 13, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
vasomotor nephropathy was documented in the medical record and was present on admission.  The Plan denied 
your request. The Plan says the billed diagnoses of N17.0 (acute kidney failure with tubular necrosis) is not 
supported in the medical record. As a result, a lower DRG was paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with N17.0 - acute kidney failure with tubular necrosis). 
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 the inpatient hospital services at the DRG 
originally billed. Our physician reviewer found there was no evidence of an ischemic or toxic injury leading to 
acute kidney injury (AKI) and acute tubular necrosis (ATN). Also, creatinine levels remained the same 
throughout hospital and did not meet the threshold for AKI. The review has determined that the documentation 
did not support N17.0 (acute kidney failure with tubular necrosis).  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on December 11, 2022, to December 13, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endosteal implants and extractions (D7210, D6010) provided 
on February 15, 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 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 15, 2023. 
Therefore, we decided that the Plan does not have to pay for endosteal implants and extractions (D7210, 
D6010) provided on February 15, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve repeat transforaminal epidural injections. 
 
You asked the Plan to pre-approve repeat transforaminal epidural injections. You say that epidural injections 
are medically necessary to treat your low back pain. The Plan denied your request. The Plan says that the 
enrollee does not meet the criteria for the requested procedure to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 repeat transforaminal epidural 
injections. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found you stated you had greater than 50% pain relief for 3 
months. Therefore, you meet the LCD criteria, and the request is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repeat transforaminal epidural injections have been met. Therefore, we decided 
that the Plan has to pre-approve repeat transforaminal epidural injections.  
 
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 more for a limited oral evaluation and cone beam computed 
tomography (CT) scan (D0140, D0366) provided on February 17, 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 you are responsible for any charged 
amount above the Plan's 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 Plan's coverage rules apply in this case. 

You have been asked to pay the difference between the out-of-network provider's charges and the Plan's 
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 a limited oral evaluation and cone beam 
computed tomography (CT) scan (D0140, D0366) provided on February 17, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 18, 2022, to 
May 31, 2022. 
 
You asked the Plan to pay for the home health services. You say that these services have been denied in error. 
The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on May 13, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the home health services 
provided from May 18, 2022, to May 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A9273 billed for date of service January 1, 
2023. 
 
You asked the Plan to pay for procedure code A9273. You say that the physician specifically requested that this 
medically necessary device be dispensed to the enrollee.  The Plan denied your request. The Plan says codes 
with a MUE value of 0 (zero) are invalid, not covered, bundled, not separately payable, statutorily excluded, or 
not reasonable and necessary in accordance with Medicare regulations or guidance.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A9273 a medical unlikely edit (MUE) value of zero (0) and is therefore not 
eligible for reimbursement. Based on this information, we decided that Medicare rules for coverage of 
procedure code A9273 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code A9273 billed for date of service January 1, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy (PT) services provided on June 13, 
2023, billed with codes 97116 and 97530. 
 
You asked the Plan to pay for the PT services as billed. You say that this was billed correctly and should be 
paid. The Plan denied your request. The Plan says the two codes at issue are not supported.  
 
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 97116 is therapeutic procedure, 1 or more areas, each 15 
minutes; gait training (includes stair climbing). The definition of code 97530 is therapeutic activities, direct 
(one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 
 
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 the PT services as billed. Our reviewer says 
that the documentation does not support codes 97116 and 97530. Our reviewer found the provided records in 
this case do not document the specific time spent for the individual therapeutic procedure, gait training 
(includes stair climbing) as required for coverage for CPT 97116. Provided records in this case also do not 
document the specific time spent for the individual therapeutic activities, direct (one-on-one) patient contact 
(use of dynamic activities to improve functional performance), as required for coverage for CPT 97530. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the PT services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the physical therapy (PT) services provided on June 13, 2023, billed with codes 97116 
and 97530.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345-GZ billed for date of service January 
30, 2023. 
 
You asked the Plan to pay for procedure code 81345-GZ. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says payment for code 81345-GZ is bundled 
into payment for code 0089U. Additionally, services billed with the GZ modifier are not payable. 
 
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 
81345-GZ is a column II code to column I code 0089U. This claim has not been billed with an appropriate 
modifier to bypass the edit. Additionally, procedure code 81345 was billed with the GZ modifier, which means 
that this service does not meet the criteria for Medicare coverage. 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 
81345-GZ billed for date of service January 30, 2023.