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

 
We decided that the Plan does not have to waive the copayment for a medical eye examination (92014) 
performed on April 28, 2020. 
 
You asked the Plan to waive the copayment for a medical eye examination. You say that this should be billed 
as an annual routine eye exam. The Plan denied your request. The Plan says the correct copayment was applied. 
 
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 $45 
copayment for each Medicare-covered outpatient visit for services to diagnose and/or treat a disease or 
condition of the eye.  
 
You have been asked to pay a $45 copayment for a medical eye examination. A medical eye examination falls 
within the "Vision 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 a medical 
eye examination (92014) performed on April 28, 2020.
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 like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested admission 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 above. 
 
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 you required moderate assistance with walking using a cane. You required 
supervision for upper body dressing. The documentation does not support that you require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that 
you require an intensive rehabilitation therapy program. Your care needs can be met at a lower 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Symbicort. 
 
You asked the Plan to pre-approve Symbicort. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee has a medical only policy which does not include Part D prescription 
coverage, therefore the criteria for self-administered drug coverage has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Symbicort.  
 
Benefits for Symbicort may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (CPT 99152) provided to the 
enrollee on March 4, 2020. 
 
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 Current Procedural Terminology (CPT) code 99152 (1 Unit) remains not supported. 
 
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 99152 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older." 
 
We asked our coding 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 the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found the report 
does not include documentation of a independent trained observer to assist in the monitoring of the enrollee's 
level of consciousness and physiological status during procedure. Therefore this code cannot be verified. 
 
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 moderate sedation services (CPT 99152) provided to the enrollee on March 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services coded 99152 provided on 
January 13, 2020. 
 
You asked the Plan to pay for the moderate sedation services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the 
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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the documentation submitted 
did not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level 
of consciousness and physiological status. Based on this information, we decided that Medicare rules for 
coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not 
have to pay for the moderate sedation services coded 99152 provided on January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management services coded 
99239 provided on February 12, 2019. 
 
You asked the Plan to pay for the hospital discharge day management services. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not 
supported by the 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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the submitted discharge 
summary does not support hospital discharge day management of more than 30 minutes was performed. A 
documented duration of time of 31 minutes or more is required to support this code. Based on this information, 
we decided that Medicare rules for coverage of the hospital discharge day management services have not been 
met. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management 
services coded 99239 provided on February 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for anesthesia for an upper gastrointestinal 
endoscopic procedure (00731) administered on January 21, 2020. 
 
You asked the Plan to waive the deductible for anesthesia for an upper gastrointestinal endoscopic procedure. 
You say that you have never been charged a deductible before and cannot afford to pay. The Plan denied your 
request. The Plan says the correct cost-sharing was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $500 deductible for outpatient hospital services, a benefit category 
which includes outpatient surgery.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category "Outpatient 
Surgery." The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 
deductible for "Outpatient Surgery." This cost sharing is a contractual obligation that had not been met at the 
time anesthesia for an upper gastrointestinal endoscopic procedure was received on January 21, 2020. 
Therefore, we decided that the Plan does not have to waive the deductible for anesthesia for an upper 
gastrointestinal endoscopic procedure (00731) administered on January 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and copayment for an inpatient hospital stay 
from May 17, 2020 to May 19, 2020. 
 
You asked the Plan to waive the deductible and copayment for an inpatient hospital stay. You say that you feel 
that the charges are too high. The Plan denied your request. The Plan says the claims were processed correctly 
and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $250 deductible for inpatient hospital stays. Your contract with the 
Plan also clearly says that after the $250 deductible has been met, enrollee's must pay a $300 copayment for 
inpatient hospital care.  
 
You had an inpatient hospital stay from May 17, 2020 to May 19, 2020. The record shows that you had paid $0 
toward the $250 deductible prior to receiving the services. Therefore, you are responsible to pay the $250 
deductible. Now that the $250 deductible has been met, you are also responsible to pay the $300 copayment. 
The total amount you owe is: $$550.  
 
The item or service you asked the Plan to waive the deductible and copayment for falls within the benefit 
category inpatient hospital care. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $250 deductible for inpatient hospital stays. This cost sharing is a contractual obligation that had not 
been met at the time an inpatient hospital stay was received on May 17, 2020 to May 19, 2020. Therefore, we 
decided that the Plan does not have to waive the deductible and copayment for an inpatient hospital stay from 
May 17, 2020 to May 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment applied to an eye exam billed for date of 
service January 14, 2020. 
 
You asked the Plan to waive the copayment applied to the eye exam. You say that the enrollee broke her 
glasses and went to the provider for repair. You say that the enrollee was not given an eye exam, but received a 
bill for the $15 copayment. The Plan denied your request. The Plan says the copayment was appropriately 
applied to the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $15 copayment for each Medicare-covered outpatient visit for services to diagnose and/or treat a 
disease or condition of the eye and for annual routine eye exams.  
 
The enrollee has been asked to pay a $15 copayment for an eye exam. The records show that the services 
provided to the enrollee on January 14, 2020 included an exam of the eyes. This means that the enrollee has 
been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment applied to an eye exam billed for date of service January 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on October 16, 2019. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for these services is correct, because the 
documentation submitted does not support the Place of Service (POS) code billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. The record shows that the sample for this testing was taken in an 
office setting, therefore the Place of Service (POS) code 81 indicating an independent laboratory setting is 
not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab 
tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing 
provided on October 16, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a pontic for tooth #20 and retainer crowns for tooth #'s 18, 19, and 21. You asked the Plan to pre-approve the pontic and retainer crowns. You say that you do not have the money to pay out of pocket. The Plan denied your request. The Plan says that the services are not medically necessary. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the pontic and retainer crowns 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 pontic and retainer crowns. Our reviewer says that these services meet criteria. Our physician reviewer found the coverage for a fixed bridge, according to the Plan, is normally for missing anterior teeth unless circumstances preclude the use of a removable prosthesis. Our reviewer found that in this case, since a fixed bridge must be removed and crowns are to be placed on teeth #'s 18, 19 and 21, a new fixed bridge replacing tooth #21 with a pontic is reasonable and necessary. 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 pontic and retainer crowns have been met. Therefore, we decided that the Plan has to pre-approve a pontic for tooth #20 and retainer crowns for tooth #'s 18, 19, and 21. 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 waive the copayment for the debridement procedure you had on 
March 5, 2020 at an outpatient hospital facility. 
 
You asked the Plan to waive the copayment for the debridement procedure. You say that you should only have 
to pay a $35 office visit because all they did was look at your toe and cut your toenails. The Plan denied your 
request. The Plan says you were charged this cost sharing correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for Medicare-covered surgery or other services provided to you an an outpatient hospital.  
 
You have been asked to pay the full amount of $154 for this debridement procedure because it is less than the 
required $325 copayment for services in an outpatient hospital facility. Debridement is considered a surgical 
procedure. 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 debridement procedure you had on 
March 5, 2020 at an outpatient hospital facility.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmology  services (99204, 92134) provided on 
December 20, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for OON ophthalmology services. You say that this was medically necessary. The 
Plan denied your request. The Plan says this was not authorized. 
 
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 has network providers 
available who can provide 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 the ophthalmology  services (99204, 92134) 
provided on December 20, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation, complete series of 
intraoral x-rays, and panoramic x-ray provided on June 9, 2020. 
 
 
You asked the Plan to pay for the comprehensive oral evaluation, complete series of intraoral x-rays, and 
panoramic x-ray. You say that you feel that you should not be charged for these services. You also say that you 
were seen for an abscessed tooth. 
 The Plan denied your request. The Plan says these services exceed the frequency limits in your benefit plan. 
 
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, oral exams and bitewing x-rays are 
each limited to 1 every six months. The record shows that you received a problem focused limited oral 
evaluation and first intraoral periapical x-ray on May 27, 2020, and your oral exams and bitewing x-rays 
benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive 
oral evaluation, complete series of intraoral x-rays, and panoramic x-ray provided on June 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 8, 2020. 
 
You asked the Plan to pay for the testing services. You say that you offer comprehensive and customized 
genetic testing panels. The Plan denied your request. The Plan says the testing is not a Medicare benefit for the 
diagnoses listed on the claim. 
 
 
 
 
 
 
 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
In this case, there are insufficient medical records that show the results of the testing will help determine a 
specific diagnosis or treatment strategy. Medicare does not cover this test for screening purposes. Therefore, 
we decided that the Plan does not have to pay for the genetic testing provided on January 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound repair services (CPT 12034) provided to the enrollee 
on March 6, 2020. 
 
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 Current Procedural Terminology (CPT) code 12034 remains not supported. 
 
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 12034 is "repair, intermediate, wounds of scalp, axillae, 
trunk and/or extremities (excluding hands and feet); 7.6 cm to 12.5 cm." 
 
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 the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
operative report does not document size of area repaired to verify CPT 12034 criteria has been met. Therefore 
this code cannot be verified. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for wound repair services (CPT 12034) provided to the enrollee on March 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis, the ankle foot orthosis, the suspension 
sleeve, the heel stabilizer, the wrist hand orthosis, and the shoulder-elbow-wrist-hand orthosis provided on 
March 12, 2020. 
 
You asked the Plan to pay for the knee orthosis (L1851), the ankle foot orthosis(L1971), the suspension sleeve 
(L2397), the heel stabilizer (L3170), the wrist hand orthosis (L3916), and the shoulder-elbow-wrist-hand 
orthosis (L3960). You say that the Plan should pay this claim. The Plan denied your request. The Plan says 
there is no itemized delivery ticket to indicate what specific supplies were provided and the invoice shows a 
different provider than the one on the claim. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. There is no itemized 
delivery ticket in the file. 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, 
the ankle foot orthosis, the suspension sleeve, the heel stabilizer, the wrist hand orthosis, and the shoulder-
elbow-wrist-hand orthosis provided on March 12, 2020.