Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) scan of thorax provided on July 
14, 2023. 
 
You asked the Plan to pay for computed tomography (CT) scan of thorax. You say that you were not told the 
hospital was not in-network. 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 computed tomography 
(CT) scan of thorax provided on July 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown and core buildup services for tooth #10 
(D2740, D2950). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as the 
enrollee disagrees with the denial. The Plan denied your request. The Plan says the services denied correctly as 
the enrollee does not meet the clinical requirements to be approved. 
 
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 dental 
services 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 pre-approve the dental services. Our physician 
reviewer found that the record provided does not indicate the enrollee meets the clinical requirements to be 
approved. Criteria are unmet. 
 
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 dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown and core buildup services for tooth #10 (D2740, D2950).
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve BIS assessment using the ImpediMed L-Dex testing device. 
 
You asked the Plan to pre-approve the ImpediMed L-Dex testing device. You say that BIS assessment using 
the ImpediMed L-Dex testing device is medically necessary. The Plan denied your request. The Plan says 
that a review of the current medical literature does not consider this service to be standard medical treatment 
for the diagnosis of lymphedema. In addition, this testing is less accurate than other testing modalities for 
lymphedema. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the ImpediMed L-Dex testing device. 
Our reviewer says that the ImpediMed L-Dex testing device is considered medically reasonable and 
necessary in this case. Our physician reviewer found that given the axillary lymph node involvement and 
treatment planned, the enrollee is at a higher risk of lymphedema. There are enough data to demonstrate 
bioimpedance as an effective clinical measure to detect early and apply prevention strategies to reduce 
lymphedema. 
 
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 ImpediMed L-Dex testing device have been met. Therefore, we decided 
that the Plan has to pre-approve BIS assessment using the ImpediMed L-Dex testing device.  
 
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 99284 for date of service July 5, 2023. 
 
You asked the Plan to pay for procedure code 99284. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the service at issue was not billed with the required modifier to allow 
separate payment within the global surgery period. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 26720 
provided on May 30, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99284 for date of 
service July 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit evaluation provided on July 31, 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 July 31, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a breath hydrogen test. 
 
You asked the Plan to pre-approve a breath hydrogen test. You say that a breath hydrogen test is medically 
necessary. The Plan denied your request. The Plan says a breath hydrogen test is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that a breath hydrogen test is covered when the criteria 
listed in the Medicare rules section of this decision are met. 
 
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 breath hydrogen test. Our reviewer 
says that the requested breath hydrogen test is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that breath testing is not warranted for bloating and constipation and is not 
medically 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 a breath hydrogen test have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a breath hydrogen test.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cane with an attached seat. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the services have been met. Despite multiple attempts from the plan, no medical records have been received for this request.. Therefore, we decided 
that the Plan does not have to pre-approve a cane with an attached seat.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99204-25 and 90833 billed for date of 
service March 28, 2023.  
 
You asked the Plan to pay for procedure codes 99204-25 and 90833. You say that the claim is billed correctly 
and should be paid. The Plan denied your request. The Plan says payment for code 99204 is bundled into 
payment for code 99205 and code 90833 is an add-on code that is not payable without an appropriate primary 
procedure. 
 
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 99204 
is a column two code to column one code 99205 with a modifier indicator of 0. The column two code is 
therefore not payable. Code 90833 is an add-on code and has not been billed with an appropriate primary 
procedure. 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 99204-25 and 90833 billed for date of service March 28, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast prosthesis garment (L8015) and sales tax (S9999), 
purchased on May 24, 2023. 
 
You asked the Plan to pay for the breast prosthesis garment and sales tax . You say that the items should be 
covered. The Plan denied your request. The Plan says this was purchased through a provider that is not enrolled 
in 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. Medicare does not reimburse separately for sales tax.  
 
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 the breast prosthesis garment (L8015) 
and sales tax (S9999), purchased on May 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis (L1852) and suspension sleeve (L2397) 
provided on May 8, 2023. 
 
You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the items were medically 
necessary. The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. There is no indication these items were needed, discussed or ordered in the clinical records 
submitted. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1852) and 
suspension sleeve (L2397) provided on May 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on May 23, 2023, to May 25, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are being overcharged. The Plan denied 
your request. The Plan says the dental services were received from an out-of-network provider and are not 
covered by your supplemental benefits.  
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided on May 23, 2023, to May 25, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic test provided on 
August 09, 2023. 
 
You asked the Plan to waive the copayment for an outpatient diagnostic test. You say that you disagree with 
the 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 $275 
copayment for outpatient diagnostic test/outpatient hospital. 
 
You have been asked to pay a $275 copayment for an outpatient diagnostic test. This item/service falls within 
the outpatient diagnostic test/outpatient 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 an outpatient diagnostic test provided on August 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99254 billed for date of service February 13, 
2023. 
 
You asked the Plan to pay for procedure code 99254. You say that the claim is billed correctly and should be 
paid. 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 99254 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code 99254 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99254 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99254 billed for date of service February 13, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network sleep study provided on 
August 16, 2023. 
 
You asked the Plan to waive the copayment for an in-network sleep study. You say that you cannot afford this 
test, you did not know there would be a copayment for it. 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 $95 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $95 copayment for an in-network sleep study. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and supplies 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 an in-network sleep study provided on August 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare Part B prescription drugs and an 
outpatient surgery provided on July 18, 2023. 
 
You asked the Plan to waive the cost share for Medicare Part B prescription drugs and an outpatient surgery. 
You say that you disagree with the cost share. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs and a $325 copayment for an outpatient surgery/Medicare-
covered outpatient hospital facility visit.  You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs and a $325 copayment 
for an outpatient surgery. The total allowed amount for the prescription drugs is $1,480.55. You are being 
asked to pay $296.11 ($1,480.55 x 20% = $296.11). However, since the allowed amount is less than the 
standard copayment for the outpatient surgery, you only owe $66.87. The total amount you are being asked to 
pay is $362.98 ($296.11 + $66.87 = $362.98). This item/service falls within the Medicare Part B prescription 
drugs and an outpatient surgery/Medicare-covered outpatient hospital facility visit 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 cost share for Medicare Part B prescription drugs and an outpatient surgery 
provided on July 18, 2023.
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 
April 20, 2023, through April 25, 2023.  
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 April 10, 2023 with Bipolar 
Disorder, Type I, Currently Depressed with Psychotic Features. 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 April 20, 2023 forward as she 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 April 20, 2023, through April 25, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral exam (D0140), intraoral imaging (D0220), and 
2D oral imaging (D0350) provided on July 28, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says these services have been processed 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for D0140 and D0220 was exhausted on date of service March 24, 2023. D0350 is not a 
covered dental benefit. Therefore, we decided that the Plan does not have to pay for a limited oral exam 
(D0140), intraoral imaging (D0220), and 2D oral imaging (D0350) provided on July 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0481 billed for date of service July 31, 
2023.  
 
You asked the Plan to pay for procedure code G0481. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says payment for code G0481 is bundled into payment for 
code 80307. 
 
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 G0481 is a column two code to column one code 80307 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 G0481 billed for date of service July 31, 2023.