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

 
We decided that the Plan does not have to waive the copayment for the vision care office visit provided on 
February 07, 2023. 
 
You asked the Plan to waive the copayment for the vision care office visit. You say that you had asked for a 
routine eye exam. 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 $25 
copayment for in-network vision care. 
 
You have been asked to pay a $25 copayment for the vision care office visit. This item/service falls within the 
in-network vision 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. The record shows this claim was approved and you are responsible for the cost share 
amount. Therefore, we decided that the Plan does not have to waive the copayment for the vision care office 
visit provided on February 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rabies vaccinations (90675) provided from February 9, 
2023, to February 16, 2023. 
 
You asked the Plan to pay for the vaccinations. You say that you were advised that your insurance would cover 
this at 100% because it is medically necessary for your work. You say that you received a bill for $743.06. You 
also say that the only reason you got these shots was because you were told it was covered at 100%. The Plan 
denied your request. The Plan says the vaccinations were not medically necessary. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccinations. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccinations. 
Therefore, we decided that the Plan does not have to pay for the rabies vaccinations (90675) provided from 
February 9, 2023, to February 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service February 21, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99100 is considered bundled and not separately payable.  
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service February 21, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mammography services provided on March 10, 2023. 
 
You asked the Plan to pay for mammography services. You say that the service was 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 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 mammography services 
provided on March 10, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 5, 2023, to 
February 3, 2023. 
 You asked the Plan to pay for the home health services. You say that the NOA has been submitted. The Plan 
denied your request. The Plan says the NOA was not received timely. As such, this final claim was correctly 
denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 5, 2023. The NOA was not received by the Plan until April 14, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from January 5, 2023, to February 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 billed for date of service February 2, 2023. 
 
You asked the Plan to pay for code 99223. You say that this code is not included in payment for any other 
codes. The Plan denied your request. The Plan says you billed the incorrect Place of Service for this code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill services with the correct 
Place of Service (POS) code.  POS 21 indicates that the service occurred in an inpatient hospital setting.  POS 
22 indicates that the service occurred in an outpatient hospital setting. 
 
In this case, you billed the service in dispute with POS 21.  However, the records show that the services 
occurred during an observation stay. Observation is an outpatient hospital setting, so POS 22 should have been 
billed instead. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99223 have not been met. Therefore, we decided that the Plan does not have to pay for code 
99223 billed for date of service February 2, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ClariFix nasal procedure (30999). 
 
You asked the Plan to pre-approve the ClariFix procedure. You say that this procedure is necessary to 
permanently improve the enrollee's symptoms and thus no longer need to use Atrovent multiple times per day. 
The Plan denied your request. The Plan says this procedure is considered an experimental and investigational 
treatment for rhinorrhea and postnasal drainage. 
 
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 the ClariFix procedure. Our reviewer 
says that the requested ClariFix procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation indicates that the enrollee has rhinorrhea and 
postnasal drainage. The reviewer found that there is insufficient literature to support the safety and efficacy, as defined by Medicare rules, of the requested service. The reviewer also found that the provided documentation 
does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested 
service. Therefore, the reviewer found that the requested Clarifix procedure is not medically reasonable or 
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 the ClariFix procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the ClariFix nasal procedure (30999).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Level IV - surgical pathology provided on January 23, 2023. 
 
You asked the Plan to pay for Level IV - surgical pathology. You say that the services should be covered. 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 Level IV - surgical 
pathology provided on January 23, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code Q0092 billed for date of service March 31, 
2023.  
 
You asked the Plan to pay for procedure code Q0092. You say that the claim is billed correctly and should be 
paid. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code Q0092 is 2. The MAI value for this code is 3. You billed 4 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code Q0092 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code Q0092 billed for date of service March 31, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested IRF admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the provided documentation does not indicate that the enrollee has complex nursing 
or rehabilitation needs. The reviewer found that while the enrollee has a need for therapy, there is no 
documentation of a need for an intensive rehabilitation program. The reviewer also found that there is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Therefore, the reviewer found that the requested IRF 
admission is not medically reasonable or 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test (81479) provided on January 25, 2023. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing is medically necessary.  The Plan 
denied your request. The Plan says the requested test does not meet requirement for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. The DEX database shows that PrismRA is not covered. Based on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. Therefore, 
we decided that the Plan does not have to pay for the PrismRA test (81479) provided on January 25, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for cone beam computed tomography (CT) capture and interpretation with 
field of view of one full dental arch  mandible (D0365) provided on February 22, 2023. 
 
You asked the Plan to pay for the cone beam CT. You say that the CT scan was done to better understand your 
risk of surgery with possible nerve damage, against not having the surgery and risking further infection. The 
Plan denied your request. The Plan says that the service is not medically necessary. 
 
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 cone 
beam CT  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 pay for the cone beam CT. Our reviewer says that 
the service is medically necessary. Our physician reviewer found without having a cone beam CT done for an 
extraction of a tooth that is close to the nerve, the nerve can be damaged, leading to temporary or permanent 
paresthesia for the enrollee. In this case, as stated in the oral surgeon's clinical notes, the location of the nerve 
would help the surgeon determine whether or not a full extraction of the tooth can be done or whether it would 
be safer to extract part of the tooth. The clinical notes that there is a cystic lesion around tooth 32, a cone beam 
CT would allow the oral surgeon to determine how much of the jawbone was affected which would also help 
guide their treatment plan and decision making with the enrollee. 
 
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 cone beam CT  have been met. Therefore, we decided that the Plan has to 
pay for cone beam computed tomography (CT) capture and interpretation with field of view of one full dental 
arch  mandible (D0365) provided on February 22, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99283 billed for date of service February 23, 
2023. 
 You asked the Plan to pay for procedure code 99283. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 99283 is bundled into payment for code 99285. 
 
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 99283 
is a column II code to column I code 99285. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99283 billed for date of service February 23, 
2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9123 billed for date of service December 6, 
2022 to December 23, 2022. 
 
You asked the Plan to pay for procedure code S9123. You say that you were advised this was a billable service.  
You said that the patient is very ill and requires services. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes.  
 
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 S9123 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9123 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9123 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9123 billed for date of service December 6, 2022 to December 23, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve a continuous glucose monitor.. You say that this device is medically 
necessary. The Plan denied your request. The Plan says that coverage rules are not met. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
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 continuous glucose monitor.. Our 
reviewer says that the requested device is medically necessary. Our physician reviewer found records show the 
enrollee is unable to use a traditional meter due to lack of thumb dexterity and as a result her a1c has risen to 
9.7;  it is reasonable and medically necessary to provide a continuous glucose monitor in this case. 
 
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 continuous glucose monitor. have been met. Therefore, we decided that the 
Plan has to pre-approve a continuous glucose monitor.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each drug administration service provided 
on June 22, 2022, to July 29, 2022. 
 
You asked the Plan to waive the copayment for each drug administration service. You say that you should only 
have a $300 copayment for each date of service. 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 $350 
copayment for in-network outpatient surgery. 
 
You have been asked to pay a $350 copayment for each drug administration service. This item/service falls 
within the in-network outpatient surgery 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. The records show the services were provided by an outpatient hospital, and 
the copayment was applied correctly. Therefore, we decided that the Plan does not have to waive the 
copayment for each drug administration service provided on June 22, 2022, to July 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telephone evaluation and management service provided on 
January 20, 2023. 
 
You asked the Plan to pay for telephone evaluation and management service. You say that the services should 
be covered. 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 telephone evaluation and 
management service provided on January 20, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 75710, 36140, and 75736 billed for date of 
service January 3, 2023. 
 You asked the Plan to pay for procedure code 75710 and 36140. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the services are not covered. 
 
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 codes 
75710 and 36140 are column II codes to column I code 37227. This claim has not been billed with an 
appropriate modifier to bypass the edit. The -59 modifier is not supported as a separate and distinct procedural 
service. Based on the claim submitted, Medicare billing criteria have not been met.  
 
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 75736 is Angiography, pelvic, selective or supraselective, 
radiological supervision and interpretation. 
 
We find that CPT code 75736 is not supported in the medical record. Specifically, there is no documentation of 
radiological supervision and interpretation of selective or supraselective pelvic angiography. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 75710, 36140, and 75736 billed 
for date of service January 3, 2023.