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

We decided that the Plan does not have to pay for the placement of an interspinous stabilization device 
provided on June 5, 2020. 
 
You asked the Plan to pay for the interspinous spacer placement. You say that this is a Medicare-covered 
service and should be paid. The Plan denied your request. The Plan says the use of this device/procedure is not 
proven based on current literature. 
 
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 pay for the interspinous spacer placement. Our 
reviewer says that the services at issue are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the device placed in this case is currently experimental. More research is needed to 
show safety and efficacy. 
 
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 interspinous spacer placement have not been met. Therefore, we decided 
that the Plan does not have to pay for the placement of an interspinous stabilization device provided on June 5, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft (D7953) provided on March 5, 
2020. 
 
You asked the Plan to pay for the bone replacement graft (D7953). You say that your dentist says the denial 
reason is incorrect. You say that after an extraction is an opportune time to do the bone replacement graft. 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 Plan's 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 the bone 
replacement graft (D7953) provided on March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible applied to the office visit you had with an out-
of-network ophthalmologist on December 30, 2019. 
 
You asked the Plan to waive the deductible applied to the out-of-network ophthalmology services. You say that 
these services should be paid. The Plan denied your request. The Plan says you had not yet met your deductible 
when you had these services, which is why you are responsible for the full cost. 
 
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 $975 deductible for out-of-network physician services.  
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $975 deductible for 
out-of-network physician services. This cost sharing is a contractual obligation that had not been met at the 
time the out-of-network ophthalmology services were received on December 30, 2019. That is why you are 
being charged the full amount for these services. Therefore, we decided that the Plan does not have to waive 
the deductible applied to the office visit you had with an out-of-network ophthalmologist on December 30, 
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 22, 2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on October 22, 2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room (ER) services you 
received on June 7, 2020. 
 
You asked the Plan to waive the copayment for the ER services. You say that the ER did not provide you with 
any care, so you shouldn't have to pay this copayment. The Plan denied your request. The Plan says you were 
charged this copayment correctly.  The Plan says that you presented to the ER with nasal congestion.  You 
were triaged and then had an initial medical screening exam by a nurse practitioner.  You then left the ER 
against medical advice prior to a full medical workup.  The plan says that you are being held responsible only 
for the allowed amount of these services ($70.67), because the allowed amount is less than your copayment 
obligation. 
 
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 $120 
copayment for emergency room services.  
 
You have been asked to pay up to a $120 copayment for the ER services. This copayment applies regardless of 
the extent of services you receive in the ER. 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 
room (ER) services you received on June 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the Pegfilgrastim injection and infusion 
service provided on May 8, 2020. 
 
You asked the Plan to waive the cost sharing for the Pegfilgrastim injection and infusion service. You say that 
you were not in a facility on this date of service. The Plan denied your request. The Plan says these cost sharing 
amounts were charged correctly.  The plan says that the facility where these services were provided are 
affiliated with the hospital listed on the bill. 
 
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 20% 
coinsurance for Medicare Part B drugs and a $30 copayment for specialty services.  
 
You have been asked to pay 20% coinsurance for the Pegfilgrastim injection and a $30 copayment for the 
infusion service. The Pegfilgrastim injection falls within the Medicare Part B drugs benefit category and the 
infusion service is a specialty physician 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 
the Pegfilgrastim injection and infusion service provided on May 8, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on May 29, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 29, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on May 
29, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $90 copayment charged for services provided on February 
20, 2020. 
 
You asked the Plan to waive this copayment. You say that you did not want to go to the emergency room, but 
your doctor insisted thinking you were having a heart attack. The Plan denied your request. The Plan says this 
cost share was charged based on your Plan contract agreement. 
 
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 $90 
copayment for emergency room services.  
 
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 $90 copayment charged for services provided on February 20, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (97110, 97112, 97140, 97164, 97530) 
provided November 6, 2019 to December 12, 2019. 
 
You asked the Plan to pay for the therapy services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does 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. 
 
We find that CPT codes 97110, 97112, 97140, 97164 & 97530 are not supported in the medical record. 
Specifically, the records do not note how much time was spent on each service. Based on this information, we 
decided that Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that 
the Plan does not have to pay for therapy services (97110, 97112, 97140, 97164, 97530) provided November 6, 
2019 to December 12, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services (01270, 37226, 75625, 75710, C1725, 
C1769, C1874, C1887, C1894, J1170, J1644, J2250, J2704, J2720, J3010, Q9967) provided on January 27, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for OON surgical services. You say that the Plan's website does not show these 
services require authorization. The Plan denied your request. The Plan says out-of-network services require 
authorization. 
 
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 surgical services (01270, 37226, 75625, 
75710, C1725, C1769, C1874, C1887, C1894, J1170, J1644, J2250, J2704, J2720, J3010, Q9967) provided on 
January 27, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee from March 23, 
2020, to April 21, 2020.  
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says if a charge is submitted for an evaluation and management (E/M) service performed as a 
separate service at the same encounter as a psychotherapy service, and a psychotherapy service is billed 
without an E/M CPT code, the Plan will re-code the charge to the corresponding psychotherapy with E/M CPT 
add-on code. The claim cannot be paid as billed due to the billing relationship in the physician's group.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this 
case, a claim for the same service for the same enrollee on the same date of services was previously paid to a 
physician in the same practicing group. Medicare rules for coverage of this service have not been met. 
Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee from 
March 23, 2020, to April 21, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
October 9, 2019 billed with CPT code 99285. 
 
You asked the Plan to pay for the ED services as billed. You say that it is felt that the correct code was used to 
describe this treatment. The Plan denied your request. The Plan says the records only support the billing of 
code 99284 and not 99285. 
 
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 these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high 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 presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function. 
 
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 ED services as billed. Our reviewer says 
that the documentation does not support the billing of a level five ED service with code 99285. Our physician 
reviewer found billing CPT 99285 requires the documentation of a comprehensive history, comprehensive 
examination and medical decision making of high complexity.  Furthermore, the complaint is usually one of 
great severity, which poses a legitimate risk to the health of the patient. In this case, the enrollee was seen in 
the ED for the second time in five days for right groin pain. His first evaluation had been benign and resulted in 
 
 
discharge. His second presentation noted no significant change in his condition. While testing was repeated, the 
medical decision making was not complex and the enrollee was once again discharged in stable condition. As 
such, the billing of CPT 99285 is not supported. 
 
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 ED services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the emergency department (ED) services provided on October 9, 2019 billed with CPT 
code 99285.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) 
provided to the enrollee on March 20, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with 
suspension sleeve (L1851, L2397) provided to the enrollee on March 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397, 
L2385) provided to the enrollee on April 6, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says there is no itemized billing/shipping invoice to verify the services billed. 
 
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 proof of delivery to support medical necessity for the supplies provided in this 
case. There is no itemized billing/shipping invoice to verify the services billed. 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 a knee orthosis with suspension sleeve (L1851, L2397, L2385) provided to the 
enrollee on April 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custodial care services provided on October 1, 2019 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the custodial care services. You say that in this case, the enrollee was admitted to 
a skilled nursing facility and your services should be covered by the plan. The Plan denied your request. The 
Plan says enrollee's 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 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 custodial care services provided on October 1, 
2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for inpatient hospital services provided by an 
out-of-network hospital from March 29, 2017, to April 1, 2017. 
 
You asked the Plan to waive the coinsurance for the inpatient hospital services. You say that you were told that 
if you were admitted through the emergency room, that your cost sharing would be limited to $600. The Plan 
denied your request. The Plan says you were charged this coinsurance 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 35% 
coinsurance for inpatient hospital care received from an out-of-network hospital.  
 
You have been asked to pay 35% coinsurance for the inpatient hospital services. Your Plan's EOC does say that 
if you get authorized inpatient care at an out-of-network hospital after your emergency condition is stabilized, 
your cost in the cost-sharing you would pay at a network hospital. In this case, however, inpatient hospital 
services at this out-of-network facility were not authorized.  
 
The hospital contacted your Plan on March 30, 2017, to request authorization for observation services, not 
inpatient services.  Observation services were authorized, but inpatient services were not.  The hospital 
admitted you as an inpatient.  Because the inpatient stay was not authorized, it was appropriate for the Plan to 
charge the out-of-network coinsurance. 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 coinsurance for inpatient 
hospital services provided by an out-of-network hospital from March 29, 2017, to April 1, 2017.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is not safe at a lower level of care, due to 
acute medical needs and being at risk for not reaching maximum potential. The Plan denied your request. The 
Plan says this request does not meet Medicare guidelines for medical necessity, because the enrollee had a 
recent change in their medical condition which requires further evaluation and treatment in the acute care 
hospital. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for 
physical and occupational therapy, but it does not support a need for an intensive rehabilitation therapy 
program. Our physician reviewer also found that there is not a reasonable expectation that this enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 IRF admission and services.