Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5261) provided on August 15, 2023. 
 
You asked the Plan to pay for hearing aids. You say that when you first purchased your hearing aids in June of 
2013, you were not required to make a pre-call to obtain this item. You also say you felt that you were 
proceeding appropriately with regard to this medical item, as you were using the same process you had used at 
the time they were first approved for payment. The Plan denied your request. The Plan says hearing aids must 
be purchased through the Plan hearing. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the hearing aids are obtained through a Plan hearing network provider.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
hearing aids (V5261) provided on August 15, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ED services provided on July 10, 2023. 
 
You asked the Plan to pay for the ED services. You say that this should be covered. 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 ED 
services provided on July 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for reline complete maxillary denture (D5750) provided on May 
22, 2023. 
 
You asked the Plan to pay for reline complete maxillary denture. You say that you did not see the denturist 
exclusion in the EOC document , but you may have missed it buried in the small print on the page you 
enclosed. You also say that you hope you may be forgiven for believing that a state licensed denturist would be 
more competent to execute these procedures than a random dentist. The Plan denied your request. The Plan 
says service performed by a hygienist or denturist is not covered. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for reline 
complete maxillary denture (D5750) provided on May 22, 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 June 26, 
2023.  
 
You asked the Plan to pay for procedure code Q0092. You say that this should be paid for. 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 June 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (D0274) and localized delivery of antimicrobial 
agents (D4381) for teeth 3 and 14, and to waive the copayment for periodontal maintenance (D4910), and 
extraction of an erupted tooth (D7140) provided from December 14, 2022, to July 10, 2022. 
 
  You asked the Plan to pay for the dental services. You say that the provider is hassling you about payment. 
You also say that you were told before that the provider was paid in full. The Plan denied your request. The 
Plan says your benefit for bitewings (D0274) has already been exhausted. The Plan also says that localized 
delivery of antimicrobial agents (D4381) is not a covered benefit. The Plan also says that the cost sharing for 
The Plan contract also says that enrollees must pay 20% coinsurance for periodontal maintenance (D4910) and 
extraction of an erupted tooth (D7140) was charged correctly. 
 
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 20% 
coinsurance for periodontal maintenance (D4910) and extraction of an erupted tooth (D7140). 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for bitewings (D0274) was exhausted on date of service March 15, 2022. The record also 
shows that localized delivery of antimicrobial agents (D4381) is excluded from this benefit.  
 
You have been asked to pay $14.28 in coinsurance, which is 20% of the allowed amount for periodontal 
maintenance (D4910) provided on December 14, 2022. You have also been asked to pay $14.66 in 
coinsurance, which is 20% of the allowed amount for periodontal maintenance (D4910) provided on March 22, 
2023. You have also been asked to pay $14.92 in coinsurance, which is 20% of the allowed amount for 
extraction of an erupted tooth (D7140) provided on July 10, 2023. Periodontal maintenance (D4910) and 
extraction of an erupted tooth (D7140) fall into the following comprehensive dental services: restorative 
services, endodontics, periodontics, and extractions 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 pay for bitewings (D0274) and localized delivery of 
antimicrobial agents (D4381) for teeth 3 and 14, and to waive the copayment for periodontal maintenance 
(D4910), and extraction of an erupted tooth (D7140) provided from December 14, 2022, to July 10, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services on May 20, 2022. 
 
You asked the Plan to pay for home health services. You say that you would like to request reconsideration for 
payment. 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 April 20, 2022. The NOA was not received by the Plan until November 9, 
2022. 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 on May 
20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient psychiatric hospital care provided from 
October 5, 2022, through October 17, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient psychiatric hospital care 
provided was not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 these services. Our reviewer says that the 
acute inpatient psychiatric hospital care provided was not medically necessary. Our physician reviewer found 
that the enrollee was admitted for acute inpatient psychiatric hospitalization on September 30, 2023 with 
Psychotic Disorder Unspecified and Alcohol Use Disorder, Severe. Based upon the review of the records 
provided, it was not expected that this enrollee would improve in a reasonable period of time for the dates in 
question as she did not have suicidal or homicidal ideation, or auditory and visual hallucinations. The enrollee 
was compliant with treatment while not showing any acute threats to safety. It did not appear medically 
necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a 
lower level of care beyond the dates in question as she did not have dangerousness to self or others and was 
compliant with her treatment. The health plans denial of continued inpatient psychiatric services is 
appropriate. This enrollee did not appear to require inpatient mental health treatment beyond the date in 
question as she was not a danger to herself or others and did not have auditory or visual hallucinations. It did 
not appear that active treatment was taking place beyond the date in question. It did not appear that the services 
were reasonably expected to improve the enrollees condition or were for the purpose of a diagnosis beyond the 
date in question. It did appear that the records were supervised and evaluated by a physician. Based upon the 
review of the records provided, the enrollee does not meet the criteria for coverage of the acute inpatient 
psychiatric hospital care provided from October 5, 2023 forward as this enrollee was not shown to be a danger 
to herself or others and did not have delusions, or auditory and visual hallucinations as noted. She was 
cooperative/compliant with treatment while not showing any threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. 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 acute inpatient psychiatric hospital care provided from October 5, 2022, through  
October 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80053, 84153, 84146 and 84403 billed for 
date of service February 1, 2023. 
 
You asked the Plan to pay for procedure codes 80053, 84153, 84146 and 84403. You say that you have billed 
the services at issue correctly. The Plan denied your request. The Plan says rules for payment 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 procedure code. 
 
We find that procedure codes 80053, 84153, 84146 and 84403 have a Status Indicator of X on the Physician 
Fee Schedule. This means that these procedure codes are not a statutory exclusion. Based on this information, 
we decided that Medicare rules for coverage of procedure codes 80053, 84153, 84146 and 84403 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 80053, 84153, 84146 and 
84403 billed for date of service February 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for application of fluoride varnish (D1206) and nitrous oxide 
(D9230) provided on May 22, 2023. 
 
You asked the Plan to pay for application of fluoride varnish and nitrous oxide. You say that the procedures 
that were performed on you were covered procedures as evidence by the list of covered procedures provided to 
you by the Plan. You also say that forcing you to sign a consent or no work would be performed constitutes a 
coercive contact. The Plan denied your request. The Plan says this is not a covered benefit, nor was this 
authorized care. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
application of fluoride varnish (D1206) and nitrous oxide (D9230) provided on May 22, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient mental health stay provided 
from July 5, 2023, to July 18, 2023. 
 
You asked the Plan to waive the copayment for the inpatient mental health stay. You say that the stay was court 
ordered. 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 $295 
copayment, per day, for days one to five for Medicare-covered hospital care each time you are admitted. 
 
You have been asked to pay a $295 copayment per day, for days one to five of the inpatient mental health stay. 
You have been asked to pay a total of $1,475 ($295 copayment x 5 days = $1,475). This item/service falls 
within the inpatient services in a psychiatric hospital benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for the inpatient mental health stay provided from July 5, 2023, to July 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service August 16, 
2023 to September 9, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that this should be paid for. 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service August 16, 2023 to September 9, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0483, 80307) provided on May 15, 2023.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the records provided do not contain lab results.

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 G0483 and 80307 are not supported in the medical record. Specifically, the documentation submitted does not contain lab results for the billed drug testing. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0483, 80307) provided on May 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement power wheelchair and accessories 
(E0955, E1007, E1012, E1028, E2300, E2311, E2313, E2361, E2607, E2620, K0108, K0861). 
 
You asked the Plan to pre-approve a replacement power wheelchair and accessories. You say that the requested 
items are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, in no case can the RUL of equipment be less 
than 5 years. The rules also say that replacement due to wear is not covered during the RUL of the equipment.  
 
The item being requested shows to be for replacement of an identical or nearly identical item, due to wear. The 
case file shows that the existing equipment is less than 5 years old. This means that replacement of this equipment due to wear is not covered at this time. Therefore, we decided that the Plan does not have to pre-
approve a replacement power wheelchair and accessories (E0955, E1007, E1012, E1028, E2300, E2311, 
E2313, E2361, E2607, E2620, K0108, K0861).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous sacroiliac fusion (posterior approach). 
 
You asked the Plan to pre-approve the percutaneous sacroiliac fusion. You say that the surgery is medically 
necessary. The Plan denied your request. The Plan says the percutaneous sacroiliac fusion is not medically 
necessary. 
 
We reviewed the Local Coverage Determination cited by the Plan and found that it is not applicable to the state 
where the requested service will be performed. 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 percutaneous sacroiliac fusion. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no sacroiliac joint instability fracture or lesion. A sacroiliac joint fusion for 
degenerative back pain is 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 the percutaneous sacroiliac fusion have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the percutaneous sacroiliac fusion (posterior approach).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services billed for date of service May 23, 2023. 
 
You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says rules for payment 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/HCPCS code. 
 
We find that the home health services at issue do not meet criteria for payment. Specifically, the services have 
been reported without a required G code to represent a visit by the appropriate HH care discipline(s). Based on 
this information, we decided that Medicare rules for coverage of home health services have not been met. 
Therefore, we decided that the Plan does not have to pay for home health services billed for date of service 
May 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2020) and progressive lenses (V2781) provided on 
August 10, 2023. 
 
You asked the Plan to pay for frames (V2020) and progressive lenses (V2781). You say that you got the 
eyeglasses with a new prescription because you need them to see. The Plan denied your request. The Plan says 
they do not cover this out-of-network vision care service or material. 
 
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 these services when the eyewear is obtained through an in-network provider.  
 
We looked at the file and the Plan's rules. The Plan rules say that any benefits received at a non-network optical 
provider are excluded from coverage. Based on this information, we decided that the Plan's rules for coverage 
of frames (V2020) and progressive lenses (V2781) have not been met. Therefore, we decided that the Plan does 
not have to pay for frames (V2020) and progressive lenses (V2781) provided on August 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have waive the cost share for the office visit provided on July 19, 2023. 
 
You asked the Plan waive the cost share for the physician service. You say that your doctor told you to come in 
to get your blood pressure checked again. You say that the nurse advised that no charge would be made. You 
also say that you received a bill for this 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 $25 
copayment for physician services in a primary physician's office.  
 
You have been asked to pay a $25 copayment for the physician service. This service falls within the physician 
services in a primary physician's office 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 waive the cost share for 
the office visit provided on July 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 84153 and 80048 provided on June 16, 
2023. 
 
You asked the Plan to pay for procedure codes 84153 and 80048. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that procedure codes 84153 and 80048 have a Status Indicator of X on the Physician Fee Schedule. 
This means that procedure codes 84153 and 80048 are a statutory exclusion. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 84153 and 80048 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 84153 and 80048 provided on June 16, 
2023.