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

 
We decided that the Plan does not have to pay for the office visit provided on June 2, 2020. 
 
You asked the Plan to pay for the office visit. You say that the Plan should pay this claim. The Plan denied 
your request. The Plan says the record shows the services are unrelated to the  Surgery period but the 
modifier is missing from the claim. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -24 modifier if the 
service billed with the modifier indicates a distinct procedural service unrelated to the  Surgery. 
 
The medical records provided show that the service billed is a distinct procedural service. However, the 
modifier -24 is missing from the claim. Based on this information, we decided that Medicare rules for coverage 
of services unrelated to the  Surgery have not been met. Therefore, we decided that the Plan does not 
have to pay for the office visit provided on June 2, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve arthroplasty of the Tempero-mandibular Joint. 
 
You asked the Plan to pre-approve arthroplasty of the Tempero-mandibular Joint. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only 
when the condition or symptom is medical in nature. The treatment must also be medically reasonable and 
necessary.  
 
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 arthroplasty of the Tempero-mandibular 
Joint. Our reviewer says that the documentation does support that the Our physician reviewer found the 
enrollee has undergone non-surgical treatments which has proved ineffective. Conservative therapies have not 
been effective. The documentation supports that the diagnosis of TMJ derangement and condylar degeneration 
are medical conditions not related to the teeth or supporting structures of the teeth. Therefore, the requested 
services are medically reasonable and 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 arthroplasty of the Tempero-mandibular Joint have been met. Therefore, we 
decided that the Plan has to pre-approve arthroplasty of the Tempero-mandibular Joint.  
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a PET/CT. 
 
You asked the Plan to pre-approve a PET/CT. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says that the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
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 a PET/CT. Our reviewer says that the 
documentation supports that the requested services are medically reasonable and necessary. Our physician 
reviewer found the enrollee has a known lung nodule. A PET/CT was ordered to evaluate given the 
immunomodulating drugs that are being used and the need to reassess the risk long term based on the 
characterization of this nodule. Whether this nodule represents malignancy or infection will directly impact 
ongoing therapy. Therefore, the enrollee meets criteria for the requested PET/CT. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a PET/CT have been met. Therefore, we decided that the Plan has to pre-
approve a PET/CT.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of denosumab (Prolia). 
 
You asked the Plan to pre-approve Prolia. You say that this drug is preferred over other medications due to 
greater efficacy given the enrollee's history of fracture. You also say that the enrollee has contraindications to 
Reclast. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, 
because the Plan requires a trial of intravenous or oral bisphosphonates before it will approve Prolia.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that the 
enrollee does not meet the Medicare criteria for a step therapy exception for Prolia. Our physician reviewer 
found the enrollee has not tried and failed the Plan's preferred drugs of intravenous or oral bisphosphonates 
 
 
(such as Reclast or Fosamax). The documentation does not indicate that these drugs would likely be less 
effective and/or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of denosumab (Prolia).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SNF stay provided from March 17, 2020, 
to April 18, 2020. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you disagree with the charges because 
this was a continuous stay and you are unhappy with the care you received. 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 $0 
copayment for days 1-20 and a $178 copayment for days 21-100 for SNF care.  
 
You had a SNF stay from March 17, 2020 to April 18, 2020. You are not being charged a copayment for days 
1-20. However, you are responsible to pay $1,389.75, which is less than the total copayment amount for days 
21-32.  
 
You have been asked to pay the total amount of $1,389.75 for a SNF stay. A SNF stay falls within the SNF 
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 SNF stay provided from March 
17, 2020, to April 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. 
 
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 you can safely receive the services you need 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for ascites. Your medical problems 
are stable. There are no identified problems that need inpatient medical management. There are no complex 
nursing or rehabilitation needs. You do 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. There is not a reasonable expectation that you will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your 
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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 80157, 80162, 80201, 80159, 
80173, and 80177 provided on November 14, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 80157, 80162, 80201, 80159, 80173, and 80177 are not supported in the medical 
record. Specifically, the specimen type collected is incorrect for the billed code. Blood specimen collection is 
by venipuncture; however, the lab requisition states a urine specimen was collected; therefore, the billed 
services cannot be verified. Based on this information, we decided that Medicare rules for coverage of the 
laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services coded 80157, 80162, 80201, 80159, 80173, and 80177 provided on November 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 95999) provided on January 9, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot 
be verified. 
 
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 95999 is ?Unlisted neurological or neuromuscular 
diagnostic procedure?. 
 
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 use 
of CPT code 95999 is not supported by the records provided. Our coding reviewer found that CPT 95999 is 
used when it is the only option for reporting a procedure performed by the provider. In this case, there is a more 
appropriate code to be reported for this procedure. 
 
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 the services (CPT 95999) provided on January 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for manual therapy techniques provided by a chiropractor from 
October 2, 2019, to June 22, 2020. 
 
You asked the Plan to pay for manual therapy. You say that these services were medically necessary for you 
and you were told that chiropractic services were covered with no limit to number of visits. The Plan denied 
your request. The Plan says the denial of payment for these services is correct, because these services are not 
covered by Medicare or the Plan when performed by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for manual therapy techniques provided by a chiropractor from October 2, 
2019, to June 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay the balance bill for emergency care professional service 
provided on June 27, 2020. 
 
You asked the Plan to pay the balance bill for emergency care. You say that you were told that this hospital 
was in-network and you stated you did not want to be seen by an out-of-network provider. The Plan denied 
your request. The Plan says the denial of payment for this amount is correct, because this provider is out-of-
network with the Plan therefore reimbursement of the balance bill amount should be followed up with the 
provider.  
 
 
 
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 $0 
copayment for emergency care professional services. The rules also say that for an out-of-network, Medicare 
participating provider, neither the Plan nor the enrollee must pay balance billing. 
 
The Plan approved coverage for this claim and assessed you no cost-sharing responsibility. The Plan paid the 
Medicare allowable amount for this claim but is not responsible for payment of the remaining balance called 
the ?balance bill? of the claim. Therefore, we decided that the Plan does not have to pay the balance bill for 
emergency care professional service provided on June 27, 2020.  
 
Please contact the billing provider regarding any amounts you are being charged beyond the allowed amount of 
this claim.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure, provisional crown, and panoramic 
x-ray provided on May 4, 2020. 
 
You asked the Plan to pay for the preventive procedure, provisional crown, and panoramic x-ray. You say that 
this is the first time you received a panoramic x-ray. You also say that your old crown came off, and this crown 
was a temporary fix while the new crown was being made. The Plan denied your request. The Plan says the 
preventive procedure and provisional crown are not covered benefits. The Plan also says that you have 
exhausted your benefit for the panoramic x-ray. 
 
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, preventive procedure and provisional 
crown are not among those covered under this benefit. The contract says that you are limited to 1 panoramic or 
full mouth x-ray per 36-month period. The record shows that you received a panoramic x-ray on March 7, 
2019, and your panoramic and full mouth x-rays benefits have been exhausted. Therefore, we decided that the 
Plan does not have to pay for the preventive procedure, provisional crown, and panoramic x-ray provided on 
May 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you will benefit from the extended 
medical and rehabilitative care. The Plan denied your request. The Plan says you can safely receive care in 
another setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that the enrollee still requires acute hospital level of care 
services and is receiving appropriate care at the present acute care hospital. The review has determined that the 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving care. There are no services available at the LTACH that the enrollee requires that 
are not available at the health care setting being offered by the health plan. The requested LTACH services are 
not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to 
be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the insertion of hardware to broken finger or thumb (26756) 
provided on July 1, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the insertion of hardware to broken finger or thumb. You say that the services 
provided were medically necessary. The Plan denied your request. The Plan says prior authorization was not 
obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 insertion of hardware to broken finger or thumb (26756) provided on July 
1, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the high strength, lightweight wheelchair 
rentals (K0004 x 2), wheelchair positioning belt (E0978), wheelchair anti-tipping device (E0971), wheelchair 
brake extension (E0961), and the wheelchair seat cushion (E2601) provided on March 26, 2020 and April 26, 
2020. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the durable medical equipment 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). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment and related supplies.  
 
You have been asked to pay $73.81 ($369.05 Plan allowed amount x 20% coinsurance) for the durable medical 
equipment provided. 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 the high strength, lightweight 
wheelchair rentals (K0004 x 2), wheelchair positioning belt (E0978), wheelchair anti-tipping device (E0971), 
wheelchair brake extension (E0961), and the wheelchair seat cushion (E2601) provided on March 26, 2020 and 
April 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a colonoscopy provided on June 15, 2020. 
 
You asked the Plan to waive the coinsurance for a colonoscopy. You say that you disagree with the charges 
because this was a routine colonoscopy. 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 20% 
coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
The medical records show that you received a diagnostic colonoscopy on June 15, 2020. The allowed amount is 
$989.22 and 20% of that is $197.84.  
 
You have been asked to pay the total coinsurance amount of $197.84 for a colonoscopy. A colonoscopy falls 
within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers 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 coinsurance for a colonoscopy provided 
on June 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Omnipod Dash 5 pack 
 
You asked the Plan to pre-approve the Omnipod Dash. You say that the omnipod dash is medically necessary. 
The Plan denied your request. The Plan says this medication is self-administered and not eligible for coverage 
under the Part B medical benefit. 
 
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 an Omnipod Dash 5 pack  
 
Benefits for the Omnipod Dash may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.