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

 
We decided that the Plan does not have to waive the copayment for each ultrasound provided on August 30, 
2023. 
 
You asked the Plan to waive the copayment for each ultrasound. You say that you feel that you are being 
overcharged. 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 $150 
copayment for other in-network Medicare-covered radiological diagnostic services, including ultrasounds. 
 
You have been asked to pay a $150 copayment for each ultrasound. This item/service falls within the other in-
network Medicare-covered radiological diagnostic services, including ultrasounds 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, the allowed amount for each 
service is less than the standard copayment, so you only owe $124.54. Therefore, we decided that the Plan does 
not have to waive the copayment for each ultrasound provided on August 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on August 30, 2023, billed 
with procedure code 99223-57. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid.  The Plan denied your request. The Plan says documentation does not support the billed code. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223-57 is initial hospital inpatient or observation care, 
per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 
We find that CPT code 99223-57 is not supported in the medical record. Specifically, the documentation 
provided did not include an evaluation and management report. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on August 30, 2023, billed with procedure code 
99223-57.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for local anesthesia (D9215), and a coronectomy (D7251) 
provided on September 21, 2023. 
 
You asked the Plan to pay for D9215 and D7251. You say that your tooth has had constant infections. The Plan 
denied your request. The Plan says the denied dental 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 local 
anesthesia (D9215), and a coronectomy (D7251) provided on September 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29581 billed for August 21, 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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that casting/splinting/strapping CPT codes shall not be 
reported for application of a dressing after a therapeutic procedure. 
 
We looked at the file and Medicare rules. The file shows that procedure code 29581 for application of a multi-
layer compression system was billed after a therapeutic procedure billed with code 11042. 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 procedure code 29581 billed for August 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
on September 18, 2023. 
 
You asked the Plan to pay for the evaluation. You say that you are requesting that the Plan consider the 
periodontal evaluation as a standard exam and reimburse accordingly. The Plan denied your request. The Plan 
says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service September 6, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) 
provided on September 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on April 28, 2023. 
 
You asked the Plan to pay for the wound care supplies. You say that you are requesting reconsideration stating 
review to reconsider your denial for payment as this is a medical necessity. The Plan denied your request. The 
Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that 
would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to 
pay for the wound care supplies provided on April 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for a heart scan provide on August 3, 2023. 
 
You asked the Plan to waive the cost for a heart scan. You say that you should not have to pay this large 
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 $100 
copayment for outpatient diagnostic tests and therapeutic services and supplies, and 20% for Medicare Part B 
prescription drugs.  
 
You have been asked to pay a $144.84 total cost for a heart scan. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies, and Medicare Part B prescription drugs 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 for a heart scan provide on August 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement of a peri-implant (D6101) on tooth #8 
provided on March 13, 2023.  
 
You asked the Plan to pay for the debridement of a peri-implant (D6101) on tooth #8. You say that you would 
like the service to be paid. You say that the service was medically necessary. The Plan denied your request. 
The Plan says the service 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 debridement of a peri-implant 
(D6101) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the debridement of a peri-implant (D6101) on tooth #8 provided on March 13, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (99285) provided on July 15, 
2023. 
 
You asked the Plan to pay for an emergency department visit (99285). You say that procedure code 99285 is 
appropriate based on the services performed. The Plan denied your request. The Plan says the records do not 
support the services at issue in this case. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 an emergency department visit (99285). Our reviewer says 
that the service at issue in this case is not supported by the medical records. Our reviewer found the enrollee 
was evaluated in the emergency department (ED) for erratic behavior, in the setting of known psychiatric 
illness. The documentation supports that an appropriate history and physical were provided; However, the 
medical decision making was not of high complexity. As such, the billing of CPT 99285 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (99285) have not been met. Therefore, we 
decided that the Plan does not have to pay for an emergency department visit (99285) provided on July 15, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or 
RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), 
amplified probe technique (87635) provided on July 11, 2023, to July 14, 2023, by an out-of-network (OON) 
provider.  
 
You asked the Plan to pay for the laboratory testing. You say that regardless of whether the clinic or provider 
verified network status or verified the requirement of prior authorization, the provider still chose to send the 
test to your lab in effort to device the treatment plan that they felt was best for their patient. The Plan denied your request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item/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 
the infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 
(SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique (87635) provided on July 11, 
2023, to July 14, 2023, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
October 06, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that this was supposed 
to be billed through your secondary plan but you cannot get them to talk to the ER. 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 $110 
copayment for emergency care. 
 
You have been asked to pay a $110 copayment for an emergency room (ER) visit. This item/service falls 
within the emergency 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. Therefore, we decided that the Plan does not have to waive the copayment for an 
emergency room (ER) visit provided on October 06, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses provided on September 18, 2023. 
 
You asked the Plan to pay for eyeglasses. You say that you understand about staying in-network for doctors, 
but it was not clear about that for the glasses and eye doctors. The Plan denied your request. The Plan says the 
services the member received must be received from an in-network provider. 
 
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 eyeglasses are obtained through a Plan vision network 
provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that you are responsible for all eyewear costs from 
providers outside of the Plan vision network. Based on this information, we decided that the Plan's rules for 
coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for 
eyeglasses provided on September 18, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 65875-59-LT billed for July 27, 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 code 65875 is not separately reportable with another procedure performed at the same 
anatomical site. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, the records show that code 65875 was billed for the same anatomical site of a previously 
covered code for the same site and is not a separate and distinct procedural service. Based on this information, 
we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met.  
Therefore, we decided that the Plan does not have to pay for procedure code 65875-59-LT billed for July 27, 
2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99349 billed for January 13, 2023, to January 16, 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 that POS code 33 must be billed with code range 99341 to 99350. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that The Plan states that code 99349 was billed incorrectly; however, 
the file shows that the claim was billed with Place of Service (POS) code 33 and the Medicare rules state that 
this POS code must be billed with code range 99341 to 99350. Code 99349 falls within this code range. The 
Plan has not provided any further binding Medicare rules or documentation to show that code 99349 is not 
payable as billed. Therefore, we decided that the Plan has to pay for procedure code 99349 billed for January 
13, 2023, to January 16, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided on September 02, 2023, to 
September 29, 2023. 
 
You asked the Plan to pay for acupuncture services. You say that previous claims for this service from this 
OON provider were reimbursed. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage rules that apply.) The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that 
would require the Plan to pay for the item(s)/service(s). The Plan has paid previous claims for reimbursement 
without authorization due to the National COVID-19 Public Health Emergency, which ended on May 11, 2023. 
Therefore, we decided that the Plan does not have to pay for acupuncture services provided on September 02, 
2023, to September 29, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would benefit from IRF services to help regain 
your strength. The Plan denied your request. The Plan says the request is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided from 
June 7, 2023, and June 27, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that you are appealing the denial 
with supporting documentation. The Plan denied your request. The Plan says this device is not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675) provided from June 7, 2023, and June 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subepithelial connective tissue graft procedures (D4273) and 
removal of torus mandibularis (D7473) provided on September 28, 2023. 
 
You asked the Plan to pay for these dental services. You say that this should be covered. The Plan denied your 
request. The Plan says these are not covered services. 
 
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 
subepithelial connective tissue graft procedures (D4273) and removal of torus mandibularis (D7473) provided on September 28, 2023.