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

 
We decided that the Plan does not have to pay for the mental health visit provided on July 17, 2023. 
 
You asked the Plan to pay for the mental health visit. 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 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 the mental health visit 
provided on July 17, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an acute inpatient stay provided on August 
27, 2023, to September 05, 2023. 
 
You asked the Plan to reduce the copayment for an acute inpatient stay. You say that these hospitals were 
connected, you should not have to pay a separate 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 $650 
copayment for inpatient hospital care.  
You have been asked to pay a $650 copayment for an acute inpatient stay. This item/service falls within the 
inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. You have been asked to pay a total of $3,250 for the inpatient hospital stay ($650 
copayment x 5 days = $3,250). You have not been charged for the day you were discharged. Therefore, we 
decided that the Plan does not have to reduce the copayment for an acute inpatient stay provided on August 27, 
2023, to September 05, 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 
July 8, 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 July 8, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from August 1, 2023, to 
August 31, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that all home health prospective payment system (HH PPS) 
claims must be submitted with type of bill (TOB) 0329.  
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the correct TOB 
code. 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 the home health services rendered from 
August 1, 2023, to August 31, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay additional reimbursement to you for the heating pad (E1399) purchased 
June 17, 2023 
 
You asked the Plan to pay additional reimbursement to you for the heating pad. You say that you were given 
incorrect information are requesting 100% reimbursement. The Plan denied your request. The Plan says that 
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). The enrollees contract with the Plan says that enrollees have $0 
copayment for Durable medical equipment (DME) and related supplies.  
 
The Plan says the enrollee must pay $11.08 coinsurance for the heating pad. The Plan had already reimbursed 
$25.84. Based on the plan contract, however, there is $0 copayment or coinsurance for Durable medical 
equipment (DME) and related supplies. Therefore, we decided that the Plan has to pay additional 
reimbursement to you for the heating pad (E1399) purchased June 17, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87798, 87481, 87653, and 87641 billed for 
date of service September 7, 2023. 
 
You asked the Plan to pay for procedure codes 87798, 87481, 87653, and 87641. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says payment for codes 
87798, 87481, 87653, and 87641 is bundled into payment for code 87801. 
 
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 
87798, 87481, 87653, and 87641 are column II codes to column I code 87801. This claim has not been billed 
with an appropriate modifier to bypass the edit as modifier 59 is not supported in the records provided. 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 codes 87798, 87481, 87653, and 87641 billed for date of service September 7, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit evaluation provided on August 09, 2023. 
 
You asked the Plan to pay for a home visit evaluation. 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 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 a home visit evaluation 
provided on August 09, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the fitting and insertion of vaginal support 
device provided on June 13, 2023. 
 
You asked the Plan to waive the copayment for the fitting and insertion of vaginal support device. You say that 
you were told this service would be covered. 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 $300 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $300 copayment for the fitting and insertion of vaginal support device. This item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities 
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 $182.19. Therefore, we 
decided that the Plan does not have to waive the copayment for the fitting and insertion of vaginal support 
device provided on June 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on August 9, 2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you thought your other plan would 
pick this up as you have a patient protection plan. 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, 
including doctors office visits. You are being asked to pay $211.42 towards this deductible. 
 
The item or service you asked the Plan to waive the copayment for falls within the physician/practitioner 
services, including doctors office visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $226 deductible which applies to physician/practitioner services, 
including doctors office visits. This cost sharing is a contractual obligation that had not been met at the time an 
office visit was received on August 9, 2023. Therefore, we decided that the Plan does not have to waive the 
copayment for an office visit provided on August 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infiltration of a sustained-release therapeutic drug 
(D9613) for tooth #40 provided by an out-of-network provider on August 15, 2023. 
  
You asked the Plan to pay for the dental service. You say that your tooth was beyond repair and the tooth 
needed to be removed to alleviate the pain. The Plan denied your request. The Plan says the denial of payment 
for this service is correct, because the infiltration of a sustained-release therapeutic drug is not covered by the 
Plan. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
infiltration of a sustained-release therapeutic drug (D9613) for tooth #40 provided by an out-of-network 
provider on August 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99232) provided on April 24, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on June 22, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the services have not been met. Therefore, 
we decided that the Plan does not have to pay for the services (99232) provided on April 24, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93005 and 93041 provided on June 25, 
2023. 
 
You asked the Plan to pay for procedure codes 93005 and 93041. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the codes billed are 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 CPT code. 
 
We find that CPT codes 93005 and 93041 are not supported in the medical record. Specifically, the codes 
billed have a status of Q1 and were billed on the same date of service as code 99285 that has a status of V. 
These codes are not separately payable. Based on this information, we decided that Medicare rules for coverage 
of procedure codes 93005 and 93041 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure codes 93005 and 93041 provided on June 25, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional neuropsychological testing (codes 96133 x2 
and 96139 x6 (8 units = 5 hours)). 
 
You asked the Plan to pre-approve additional neuropsychological testing. You say that the neuropsychological 
exam was requested to assist with differential diagnosis of patient-reported concerns for age advanced 
neurocognitive and functional changes. The Plan denied your request. The Plan says there is no documentation 
why this extended testing time is medically necessary. 
 
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 additional neuropsychological testing. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the records provided show this patient has had difficulty with cognitive 
concerns however the neuropsychological testing is extended exceeding the 8 hours required for testing. Based 
on the premise that this testing is intended to diagnose and characterize the neurocognitive effects of medical 
disorders that impinge directly on or indirectly on the brain including detection of neurologic disease based on 
quantitative assessment of neurocognitive abilities, differential diagnosis between psychogenic and neurogenic 
syndromes, delineation of neurocognitive effects of central nervous system disorders, neurocognitive 
monitoring of recovery or progression of central nervous system disorders or assessment of neurocognitive 
function for the formulation of rehabilitation and/or management strategies among individuals with 
neuropsychiatric disorders, the need for this patient is not documented for extended neuropsychological testing. 
Our reviewer also found that as this testing is normally accomplished in the time allotted, it does not require 
exceeding the required time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional neuropsychological testing have not been met. Therefore, we decided 
that the Plan does not have to pre-approve additional neuropsychological testing (codes 96133 x2 and 96139 x6 
(8 units = 5 hours)).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Corflex interlaminar/interspinous stabilization device 
 
You asked the Plan to pre-approve a Corflex stabilization device. You say that the enrollee would benefit from 
this device. The Plan denied your request. The Plan says this procedure is considered experimental. 
 
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 a Corflex stabilization device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested device is considered experimental. 
 
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 Corflex stabilization device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Corflex interlaminar/interspinous stabilization device
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 28, 2023. 
 
You asked the Plan to pay for an office visit. You say that you cannot afford to pay for these services that you 
need. 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 an office visit provided 
on July 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each Part B injection provided on 
September 22, 2023. 
 
You asked the Plan to waive the coinsurance for each Part B injection. You say that you cannot afford to pay 
the amount. 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 20% 
coinsurance for Medicare Part B prescription drug. 
 
You have been asked to pay 20% coinsurance for each Part B injection. This item/service falls within the 
Medicare Part B prescription drug 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 total amount you owe is $181.64, which is 20% coinsurance of the allowed 
amount for each item. Therefore, we decided that the Plan does not have to waive the coinsurance for each Part 
B injection provided on September 22, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on May 
31, 2023. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you are having a hard 
time with the amount due as it was not you choosing the mode of transportation. 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 $325 
copayment for ambulance services. 
 
You have been asked to pay a $325 copayment for the ambulance services. This item/service falls within the 
ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance 
services provided on May 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lipid panel test (80061) provided April 18, 2023. 
 
You asked the Plan to pay for the laboratory testing. You say that this lab was done for your annual physical 
and you believe this should be covered. The Plan denied your request. The Plan says the enrollee has exceeded 
the benefit limit. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of cardiovascular 
disease testing once every 5 years (60 months).  
 
Based on review of the file, cardiovascular disease testing was provided less than 5 years prior to the visit at 
issue in this case. Therefore, we decided that the Plan does not have to pay for the lipid panel test (80061) 
provided April 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) 
and electronic connection (E2311), and armrests, elbow supports and positioning wedges. 
 
You asked the Plan to pre-approve an expandable controller with harness and electronic connection, and 
armrests, elbow supports and positioning wedges.. You say that the requested items are a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the requested items are not medically necessary. 
 
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 an expandable controller with harness 
and electronic connection, and armrests, elbow supports and positioning wedges.. Our reviewer says that the 
requested items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided records document that the enrollee has 3/5 left upper extremity strength and is 
independent with feeding, thus indicating that the enrollee has adequate upper-extremity strength and function 
to operate the wheelchair's power options with their own switches. The provided records do not support a medical need for separately billed armrests, elbow supports or positioning wedges. The rules state that separate 
billing of these components is incorrect coding. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller with harness and electronic connection, and armrests, 
elbow supports and positioning wedges. have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an expandable controller (E2377) with harness (E2313) and electronic connection (E2311), and 
armrests, elbow supports and positioning wedges.