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

 
We decided that the Plan does not have to pay for the debridement and the chemical cauterization provided on 
September 11, 2023. 
 
You asked the Plan to pay for the debridement and the chemical cauterization. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 debridement and the chemical cauterization provided on September 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
September 22, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service September 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (A4239) provided on 
July 8, 2023. 
 
You asked the Plan to pay for the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as they do not meet the clinical 
requirements to be approved. 
 
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 a continuous glucose monitor (CGM) 
(A4239) provided on July 8, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an abdomen and pelvis computed 
tomography (CT) scan with contrast provided on September 28, 2023. 
 
You asked the Plan to waive the copayment for an abdomen and pelvis computed tomography (CT) scan with 
contrast. You say that you were never told that there would be a 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 $350 
copayment for all other outpatient diagnostic and therapeutic services and supplies, such as CT scans. 
 
You have been asked to pay a $350 copayment for an abdomen and pelvis computed tomography (CT) scan with contrast. This item/service falls within the all other outpatient diagnostic and therapeutic services and 
supplies, such as CT scans 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 
$243.56. Therefore, we decided that the Plan does not have to waive the copayment for an abdomen and pelvis 
computed tomography (CT) scan with contrast provided on September 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies (A4239) provided on August 14, 2023. 
 
You asked the Plan to pay for the diabetic supplies. You say that this supply allowance was medically 
necessary. The Plan denied your request. The Plan says the billed amount exceeds the amount allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that billing more than one (1) unit of service per 
thirty (30) days of code A4238 or A4239 will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Three units of code A4239 were already paid between July and 
August 2023. Based on this information, we decided that Medicare rules for coverage of the diabetic supplies 
have not been met. Therefore, we decided that the Plan does not have to pay for diabetic supplies (A4239) 
provided on August 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for caries-arresting medication application, per tooth 
(code D1354) provided on September 5, 2023. 
 
You asked the Plan to pay for caries-arresting medication application, per tooth. The Plan denied your request. 
The Plan says this service is not a covered dental benefit. 
 
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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for caries-arresting 
medication application, per tooth (code D1354) provided on September 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95907 billed for date of service July 31, 
2023.  
 
You asked the Plan to pay for procedure code 95907. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 95907 is bundled into payment for code 
95861. 
 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 95907 
is a column two code to column one code 95861 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 procedure code 95907 billed for date of service July 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient consultation provided on August 31, 2023. 
 
You asked the Plan to pay for the inpatient consultation. You say that you are requesting reconsideration for the 
services provided. 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 inpatient consultation provided on August 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient rehabilitation services provided on May 10, 2023, 
through August 11, 2023. 
 
You asked the Plan to pay for outpatient rehabilitation services. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
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. Specifically, a Medicare identification number for the facility is not on file. Therefore, we decided 
that the Plan does not have to pay for outpatient rehabilitation services provided on May 10, 2023, through 
August 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and the laboratory services provided on July 
14, 2023. 
 
You asked the Plan to pay for an office visit and the laboratory services. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 an office visit and the laboratory services provided on July 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit, and debridement of nails provided on August 
31, 2023. 
 
You asked the Plan to pay for a home visit, and debridement of nails. 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 a home visit, and debridement of nails provided on August 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (A4239) provided on 
July 21, 2023. 
 
You asked the Plan to pay for the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items 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 a continuous glucose monitor (CGM) 
(A4239) provided on July 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on December 7, 2022, billed 
with procedure code 99238. 
 
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 documentation does not support the billed code. 
 
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 find that CPT code 99238 is not supported in the medical record. Specifically, the documentation provided 
does not include medical records for the date of service in question. 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 December 7, 2022, billed with procedure 
code 99238.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services described by code 01992 billed for 
date of service January 11, 2023. 
 
You asked the Plan to pay for 01992. You say that 01992 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says 01992 is denied because the diagnosis code 
assigned does not support medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnosis code M79.18 is not listed as a 
diagnosis code that supports medical necessity when billing procedure code 01992. 
 
We looked at the file and Medicare rules. In this case we have confirmed that procedure code 01992 was billed 
with a diagnosis of only M79.18, defined as myalgia, other site. No additional diagnoses were listed on the 
claim. We confirmed that per LCA A57361, M79.18 does not support medical necessity when billing 01992. 
As such, the denial of 01992 is appropriate. Based on this information, we decided that Medicare rules for coverage of 01992 have not been met. Therefore, we decided that the Plan does not have to pay for the 
anesthesia services described by code 01992 billed for date of service January 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation with a medicinal agent-per quadrant 
(D4921 x 4) provided on July 6, 2023. We also decided that the Plan does not have to waive the coinsurance 
for the periodontal maintenance (D4910) provided on July 6, 2023. 
 
You asked the Plan to pay for the gingival irrigation services. Additionally, you asked the Plan to waive the 
coinsurance for the periodontal maintenance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the gingival irrigation services provided are 
not covered under the supplemental dental policy. Additionally, the Plan says that you must pay a 50% 
coinsurance for the periodontal maintenance provided.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
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 periodontal maintenance.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the gingival irrigation services 
provided in this case are not among those covered under this benefit. Additionally, you were asked to pay 
$32.50 (Plans allowed amount of $65 x 50% coinsurance) for the periodontal maintenance provided in this 
case. This means that you have been asked to pay the correct amount based on your contract with the Plan. This 
cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided 
that the Plan does not have to pay for the gingival irrigation with a medicinal agent-per quadrant (D4921 x 4) 
provided on July 6, 2023. We also decided that the Plan does not have to waive the coinsurance for the 
periodontal maintenance (D4910) provided on July 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 2, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the enrollee has been given the run around by 
the Plan. 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 May 4, 2023. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 2, 
2023.  
 
Your complaint about the enrollee potentially receiving poor customer service from the Plan is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility visit provided on August 08, 2023. 
 
You asked the Plan to pay for a facility visit. You say that this was medically necessary and 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 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 a facility visit provided on August 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services, the radiology services, and the saline 
solution provided on August 15, 2023, to October 03, 2023. 
 
You asked the Plan to pay for the injection services, the radiology services, and the saline solution. You say 
that you are requesting reconsideration of the denied claim. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 injection services, the radiology services, and the saline solution provided on August 15, 2023, to 
October 03, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on August 
9, 2023. 
 
You asked the Plan to pay for the ED services. You say that you have submitted medical records for processing 
of the claim. The Plan denied your request. The Plan says Medicare payment cannot be made to this type of 
provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on August 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a recumbent bicycle (A9300). 
 
You asked the Plan to pre-approve a recumbent bicycle. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says a recumbent bicycle is not covered by Medicare or 
the Plan. 
 
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 a recumbent bicycle (A9300).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to provide massage therapy. 
 
You asked the Plan to provide massage therapy. You say that you pain management doctor feels this would 
help alleviate or manage your back pain. The Plan denied your request. The Plan says that their original 
decision to deny coverage was correct. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to provide massage therapy.