Persius/hicric huggingface dataset:
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 
February 14, 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 February 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lenses fitting provided on April 11, 2023. 
 
You asked the Plan to pay for the contact lenses fitting. You say that the contact lens fitting should have been 
coded as medically indicated. You say this means the contact lenses should be covered. The Plan denied your 
request. The Plan says the service is not a covered benefit. 
 
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 says contact lens fittings are excluded from coverage. 
 
We looked at the file and the Plan's rules. Specifically, the service is not a covered benefit. Based on this 
information, we decided that the Plan's rules for coverage of the contact lenses fitting have not been met. 
Therefore, we decided that the Plan does not have to pay for the contact lenses fitting provided on April 11, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the premium progressive lenses, the impact resistance, the 
oversized lenses, the anti-glare, and the ultraviolet (UV) protection provided on February 6, 2023. 
 
You asked the Plan to pay for the vision services. You say that you received a denial saying that your glasses 
were not covered. You say that you are being billed the balance. The Plan denied your request. The Plan says 
the services are not covered benefits and the copayment was applied correctly. 
 
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 not covered services. 
 
We looked at the file and the Plan's rules. Specifically, the services are not covered benefits. Based on this 
information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, 
we decided that the Plan does not have to pay for the premium progressive lenses, the impact resistance, the 
oversized lenses, the anti-glare, and the ultraviolet (UV) protection provided on February 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drugs or medicaments dispensed in the office for home use 
(D9630) provided on January 26, 2023. 
 
You asked the Plan to pay for 9630. You say that these services should be covered. The Plan denied your 
request. The Plan says D9630 is not a covered 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for drugs or 
medicaments dispensed in the office for home use (D9630) provided on January 26, 2023. 
 
All other services provided have been reprocessed and paid by the Plan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99222) rendered on 
January 26, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this service is not supported without the required documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99222 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that there is not a comprehensive 
history or a plan of at least moderate decision making to meet criteria for CPT 99222. 
 
We looked at this coder's review, the file, and Medicare rules. 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 initial hospital care (procedure code 99222) rendered on January 26, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 95822 and 95927 rendered on April 20, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the records do not support the services 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. In this case, the CPT Code Manual definition of 
the denied codes is: 
 
CPT 95822: 
 
Electroencephalogram (EEG); recording in coma or sleep only 
 
CPT 95927: 
 
Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, 
recording from the central nervous system; in the trunk or head 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of the technical report 
does indicate that an EEG was performed. However, this code is not supported as the enrollee was not in a 
coma or sleep. There are more appropriate codes to use in this clinical scenario. (e.g., 95812 and 95813). 
Therefore, the records do not support that CPT 95822 was rendered.  
 
In terms of CPT 95927, the technical report cites recording sites for the SSEP (somatosensory evoked 
potential) were the ulnar nerve and posterior tibial. Neither of these would be in the trunk or head. Therefore, 
records do not support that CPT 95927 was rendered. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
procedure codes 95822 and 95927 rendered on April 20, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laparoscopic cholecystectomy (47562) provided on 
December 3, 2022. 
 
You asked the Plan to pay for the surgical service. You say that the out-of-network was the only available 
assistant at the time of the procedure. You also say that the rendered service was specifically requested by the 
in-network primary physician and in-network facility. You also say that the enrollee cannot choose who 
assisted with their surgery. The Plan denied your request. The Plan says the provider is not eligible for payment 
from Medicare. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the laparoscopic cholecystectomy 
(47562) provided on December 3, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on December 15, 2022. 
 
You asked the Plan to pay for nursing facility care. You say that you are appealing the claim payment denial. 
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 nursing facility care 
provided on December 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam CT capture and interpretation (D0367) provided 
on April 6, 2023. 
 
You asked the Plan to pay for cone beam CT. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
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 cone 
beam CT capture and interpretation (D0367) provided on April 6, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for facet joint injections performed at an 
ambulatory surgical center provided on December 12, 2022. 
 
You asked the Plan to waive the copayment for facet joint injections performed at an ambulatory surgical 
center. You say that you should not be responsible to pay for injections that were a prerequisite to another 
procedure that was denied by the 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment for outpatient surgery. 
 
You have been asked to pay a $225 copayment for facet joint injections performed at an ambulatory surgical center. This item/service falls within the outpatient surgery benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for facet joint injections performed at an ambulatory surgical center provided on 
December 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for custom fabricated abutment (D6057), and abutment 
supported crown (D6058) provided on February 23, 2023. 
 
You asked the Plan to pay for D6057 and D6058. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the denied services are not covered 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. 
 
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 custom 
fabricated abutment (D6057), and abutment supported crown (D6058) provided on February 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pedicle soft tissue graft procedure (D4270) provided on 
February 21, 2023. 
 
You asked the Plan to pay for the pedicle soft tissue graft procedure. You say that the services in dispute were 
necessary to the enrollee's treatment plan. You also say that the services were not cosmetic in nature. The Plan 
denied your request. The Plan says D4270 is not listed as covered under the Plan's dental 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. 
 
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 pedicle 
soft tissue graft procedure (D4270) provided on February 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam CT (D0367) and radiographic/surgical implant 
index (D6190) provided on April 17, 2023. 
 
You asked the Plan to pay for cone beam CT and radiographic/surgical implant index. You say that this should 
be covered. The Plan denied your request. The Plan says this is not a covered service. 
 
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 cone 
beam CT (D0367) and radiographic/surgical implant index (D6190) provided on April 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard  hard appliance, full arch (D9944) 
provided on November 17, 2022. 
 
You asked the Plan to pay for the occlusal guard. You say that this item was prescribed by your doctor and you 
don't understand why it's not covered. The Plan denied your request. The Plan says procedure code D9944 is 
not a covered service under the dental benefit or optional supplemental 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
occlusal guard  hard appliance, full arch (D9944) provided on November 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on March 
24, 2022, to April 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 a comprehensive oral evaluation (D0150) provided on March 24, 2022, to April 4, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit advanced care planning provided on December 
19, 2022, by an OON provider.  
 
You asked the Plan to pay for home visit advanced care planning. You say that you are appealing the claim 
payment denial. The Plan denied your request. The Plan says the services were provided out-of-network and 
were not approved in advanced. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for home visit advanced care planning provided on 
December 19, 2022, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit system (K0108) and power seat elevation 
system (E2300). 
 
You asked the Plan to pre-approve a transit system and power seat elevation system. You say that you strongly 
believe that having a sophisticated power wheelchair will allow the enrollee to stay at home and stay healthy. 
The Plan denied your request. The Plan says the power seat elevation system (E2300) is not considered medical 
in nature and the transit system (K0108) is also not covered because it is used outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare rules also say that a power seat elevation feature (E2300) is non-
covered because it is not primarily medical in nature. 
 
 The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a transit system (K0108) and power seat elevation system (E2300).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit provided 
on April 01, 2022, to April 15, 2022. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) visit. You say that you do not agree 
with the cost share applied for the service rendered. 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 $35 
copayment for outpatient rehabilitation service. 
 
You have been asked to pay a $35 copayment for each physical therapy (PT) visit. This item/service falls 
within the outpatient rehabilitation service 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 you owe is $140 for PT services ($35 per visit x 4 visits = $140). 
Therefore, we decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit 
provided on April 01, 2022, to April 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on March 26, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that you are submitting the claim filing as a 
good cause of timely filing for the aforementioned date of service for your kind perusal. The Plan denied your 
request. The Plan says the claim was untimely and the submission did not meet the exception criteria 
guidelines. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
 
 The record shows that a claim for the ambulance services was not filed until October 12, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport, 
and ground mileage provided on March 26, 2021.
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 
August 16, 2022.  
 
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 August 16, 2022.