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

 
We decided that the Plan does not have to pay for the surgical services rendered on July 15, 2020. 
 
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 procedure code 22846 is 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 22846 is anterior instrumentation; 4 to 7 vertebral 
segments (List separately in addition to code for primary procedure). 
 
We find that CPT code 22846 is not supported in the medical record. Specifically, there is no documentation of 
anterior instrumentation for 4 to 7 vertebral segments. 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 surgical services rendered on July 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction (D7210 x 3), the filling (D2331), the 
consultation (D9310), the comprehensive oral evaluations (D0150 x 2), the fillings (D2331 x 2), the immediate 
upper denture (D5221), the denture adjustment (D5650), the extraction (D7140), the crown re-cement (D2920), 
the filling (D2392), the filling (D2335), the crown (D2740), and the unspecified restorative service (D2999) 
provided from June 8, 2020, to August 10, 2020. 
 
You asked the Plan to pay for the dental services. You say that you are aware that this provider is not in 
network. You say that the dentist you went to in your location is not up to your standards. You say that you 
cannot drive far due to your health. You say that going to dentists outside of your town are not feasible. You 
also say that the dental office was subpar. The Plan denied your request. The Plan says the provider in this case 
is out of network. The Plan also says that dental services that you receive out of network are not covered. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dental services that you received out of 
network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the surgical extraction (D7210 x 3), the filling (D2331), the consultation (D9310), the comprehensive 
oral evaluations (D0150 x 2), the fillings (D2331 x 2), the immediate upper denture (D5221), the denture 
adjustment (D5650), the extraction (D7140), the crown re-cement (D2920), the filling (D2392), the filling 
(D2335), the crown (D2740), and the unspecified restorative service (D2999) provided from June 8, 2020, to 
August 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for a Denosumab injection (J0897) and a 
therapeutic injection (96372) provided on September 18, 2020. 
 
You asked the Plan to waive the cost-sharing for a Denosumab injection and a therapeutic injection. You say 
that you don't understand these charges. The Plan denied your request. The Plan says these services processed 
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 $5 
copayment for laboratory services and pay a 20% coinsurance for each Medicare-covered Part B drug. 
Additionally, for the administration of that drug, you will pay the cost-sharing that applies to primary care 
provider services, specialist services, or outpatient hospital services. 
 
You have been asked to pay a $238.80 coinsurance for a Denosumab injection ($1,194 allowed amount x 20% 
= $238.80) and a $5 copayment for a therapeutic injection, which has processed as a laboratory service. 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-sharing for a Denosumab injection (J0897) and a therapeutic injection 
(96372) provided on September 18, 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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services needed in other settings. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for weakness and 
pneumonia. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient 
admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record documents a need for physical and occupational therapy, it does not 
document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve the requested services. You say that your knee is causing your hip and back 
to hurt. The Plan denied your request. The Plan says peripheral nerve destruction using cryoablation, laser, 
electrical, chemical, or radiofrequency ablation is considered experimental for knee pain. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that you have chronic knee pain after a total knee arthroplasty. You have had physical therapy, 
a home exercise program, heat and cold therapy, without sustained benefit. You had diagnostic genicular nerve 
blocks and achieved 100% pain relief for three days. The requested service is considered an experimental/ 
investigational procedure that is the subject of on-going clinical trials. It's role in post procedure has not been 
defined yet. Therefore, the request is considered not medically reasonable or 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care provided to the enrollee from February 8, 
2021, forward. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the 
case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to 
pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer 
found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service 
needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not 
meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. We looked at this 
physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve 
SNF care provided to the enrollee from February 8, 2021, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ECG provided on July 7, 2020. 
 
You asked the Plan to waive the copayment for an ECG. You say that you disagree with the charges because 
you thought all copayments were waived due to COVID-19. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for non-radiological diagnostic services. 
 
You received an ECG on July 7, 2020. Non-radiological diagnostic services are not included in the copayment 
waiver for COVID-19. Therefore, you are responsible to pay the total allowed amount of $20.94, which is less 
than the $30 copayment.   
 
You have been asked to pay $20.94 for an ECG. An ECG 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 ECG provided on July 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5261) purchased on June 5, 2020. 
 
You asked the Plan to pay for hearing aids. You say that you were instructed by a representative of the Plan to 
use a non-contracted provider. The Plan denied your request. The Plan says rules for payment have not been 
met. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan?s coverage rules apply in this case. The Plan pays for 
hearing aids only when received from a Plan-contracted provider. 
 
We looked at the case file and the Plan's rules. You received hearing aids from a non-contracted provider. 
Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. 
Therefore, we decided that the Plan does not have to pay for hearing aids (V5261) purchased on June 5, 2020.  
 
Your complaint about receiving erroneous or ambiguous information about your benefit from a representative 
of the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be 
answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for radiology services (74240, 72040, 74230) provided July 31, 2020. 
 
You asked the Plan to pay for the radiology services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says that they were unable to make a determination within the allotted 
60 day timeframe. The plan's original denial states the number of services rendered exceeds the amount 
allowed under plan guidelines. 
 
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. The plan's original denial reason states that "This procedure exceeds the 
maximum number or services allowed under our guidelines for a single date of service". The plan did not 
provide any details of the guidelines or cite any CMS criteria used to make this determination. The Section of 
the appeal packet labeled "Decision Making Criteria" included only the cover page of the 2020 Evidence of 
Coverage. The documentation submitted by the plan to the IRE does not clearly support the denial. Therefore, 
we decided that the Plan has to pay for radiology services (74240, 72040, 74230) provided July 31, 2020.  
 
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 waive the copayment for emergency care provided. 
 
You asked the Plan to waive the copayment for emergency care. You say that the emergency room did nothing 
for your broken tooth and you disagree with the charges. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for emergency care.  
 
You have been asked to pay a $25 copayment for emergency care. Emergency care 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 emergency care provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on October 14, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. 
The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the 
referring provider is also out-of-network. 
 
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 physician services provided on October 14, 2020 
by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Mohs micrographic technique (17311) provided on 
December 18, 2019. 
 
You asked the Plan to pay for the Mohs micrographic technique. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the documentation does not 
support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We 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 Mohs micrographic technique. Our reviewer says that 
CPT code 17311 does not meet criteria for billing or reimbursement consideration. Our reviewer found the 
medial records provided do not include sufficient documentation to validate that this provider acted as surgeon 
and performed the Mohs procedure as well, therefore this service 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 Mohs micrographic technique have not been met. Therefore, we decided 
that the Plan does not have to pay for the Mohs micrographic technique (17311) provided on December 18, 
2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
March 6, 2019, to March 8, 2019. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you have never had to 
pay a copay before and you would like to appeal this decision. The Plan denied your request. The Plan says this 
claim was processed and the correct copayment was applied per the Evidence of Coverage. 
 
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 $372 
copay each day for days 1-5 for the inpatient hospital care.  
 
You have been asked to pay $744.00 ($372 x 2 days = $744) for the inpatient hospital care. The inpatient 
hospital care falls within the Inpatient hospital 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 the inpatient hospital care provided from March 6, 2019, to March 8, 2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit (99284) provided 
on July 29, 2020. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not have to 
pay a copayment since you were not admitted to the hospital and you went to the emergency room because 
your cardiologist told you to. The Plan denied your request. The Plan says emergency room services were 
provided and are subject to a $100 copayment per visit if you are not admitted to the hospital within 24 hours 
for the same condition. 
 
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 emergency care.  
 
You have been asked to pay a $100 copayment for an emergency room visit. An emergency room visit falls 
within the emergency care benefit category. Services were provided in the emergency department and you were 
not admitted to the hospital afterward. 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 emergency room 
visit (99284) provided on July 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on June 10, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. 
The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 physician services provided on June 10, 2020 by 
an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or 
therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria 
for an inpatient basis in a skilled nursing facility setting.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.