Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray and additional intraoral 
periapical x-ray provided on May 19, 2020. 
 
You asked the Plan to pay for the first intraoral periapical x-ray and additional intraoral periapical x-ray. You 
say that you were billed for services that you never received. You also say that you only had one x-ray taken, 
not a series with extra films. The Plan denied your request. The Plan says these services 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, 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 first 
intraoral periapical x-ray and additional intraoral periapical x-ray provided on May 19, 2020.  
 
Your complaint about this provider and the dental office 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the placement of biodegradable material (55874) provided on 
November 14, 2019. 
 
You asked the Plan to pay for the placement of biodegradable material. You say that this code is supported. 
The Plan denied your request. The Plan says that CPT 55876 would be more appropriate for the service 
performed. 
 
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 55874 is transperineal placement of biodegradable material, peri-prostatic, single or multiple injection(s), 
including image guidance, when performed. 
 
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 placement of biodegradable material. 
Our reviewers says that this code is supported by the records. Our physician reviewer found the medical 
records provided indicate that both fiducial markers (55876) were placed and Space OAR hydrogel was placed 
into the rectoprostatic fascia. The Space OAR placement is validated and represented by CPT code 55874. 
 
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 placement of biodegradable material have been met. Therefore, we decided 
that the Plan has to pay for the placement of biodegradable material (55874) provided on November 14, 2019.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assisted living services provided on June 23, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for assisted living services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the 
provider or the facility; 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 assisted living services provided on June 23, 2020 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on January 30, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider 
on January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nail debridement (11721), removal of nail plate (11730), 
and the trimming of skin lesions (11057) rendered by the out of network (OON) provider on May 19, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. 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 the nail debridement (11721), removal of nail plate (11730), and the trimming of skin 
lesions (11057) rendered by the out of network (OON) provider on May 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a prostate biopsy (G0416) performed on 
March 31, 2020. 
 
You asked the Plan to waive the deductible for a prostate biopsy. You say that this cost-sharing should be paid 
by the Plan. 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 services including consultation, diagnosis, and 
treatment by a specialist.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
Physician/Practitioner services, including doctor's office visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $500 deductible for services including consultation, diagnosis, 
and treatment by a specialist. This cost sharing is a contractual obligation that had not been met at the time a 
prostate biopsy was received on March 31, 2020. Therefore, we decided that the Plan does not have to waive 
the deductible for a prostate biopsy (G0416) performed on March 31, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 14, 2019. 
 
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 codes 80299 and 80307 are 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 80299 is quantitation of therapeutic drug, not elsewhere 
specified. The definition of code 80307 is drug test(s), presumptive, any number of drug classes, any number of 
devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, 
FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without 
chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) 
includes sample validation when performed, per date of service. 
 
We find that CPT codes 80299 and 80307 are not supported in the medical record. Specifically, there is no 
documentation that quantitation of therapeutic drug testing was ordered to support code 80299. The testing 
results contain only confirmatory results and no definitive results to support code 80307. 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 laboratory services rendered on November 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management service provided on 
February 19, 2020. 
 
You asked the Plan to pay for the hospital discharge day management service (99239). You say that the Plan 
should pay this claim. The Plan denied your request. The Plan says the enrollee had elected the hospice benefit 
on the date of service. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospital discharge day management service provided on 
February 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Certolizumab pegol injection provided 
on June 1, 2020. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you cannot afford this. The Plan 
denied your request. The Plan says that you were charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for the injection. The injection falls within the Medicare Part B 
prescription drugs benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Certolizumab 
pegol injection provided on June 1, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for Medicare Part B drugs (J0178 and J2778) 
and diagnostic retinal imaging (92134) received from January 8 to April 30, 2020. 
 
You asked the Plan to waive the cost-sharing for Medicare Part B drugs and diagnostic retinal imaging. You 
say that the Plan should be covering all or part of these charges. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for drugs covered under Medicare Part B and a $25 copayment for physician specialist services.  
 
You have been asked to pay $1,853.07, or 20% coinsurance of the Plan-allowed amount of $9,265.31, for 
Medicare Part B drugs, and $125, or a $25 copayment for 5 physician specialist services, for diagnostic retinal 
imaging. Medicare Part B drugs fall within the "Medicare Part B prescription drugs" benefit category. 
Diagnostic retinal imaging falls within the "Physician/Practitioner Services, including doctor's office visits" 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the cost-sharing for Medicare Part B drugs (J0178 
and J2778) and diagnostic retinal imaging (92134) received from January 8 to April 30, 2020.
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 April 23, 2020. 
 
You asked the Plan to waive the copayment for the ER services. You say that you should not have to pay this 
copayment because the ER didn't do enough to warrant the payment. The Plan denied your request. The Plan 
says you were charged this amount 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 $90 
copayment for emergency room services.  
 
You have been asked to pay a $90 copayment for the ER services. This amount applies regardless of the extent 
of services received 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 April 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laminotomy/hemilaminectomy 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no longer any central or subarticular recess stenosis requiring laminectomy 
and/or discectomy. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the imaging studies do not support the need for surgery. There is no severe nerve root 
compression. Surgery is not needed. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve laminotomy/hemilaminectomy
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing 
facility. 
 
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 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 
acute on chronic kidney disease and dementia with failure to thrive. Medications have been adjusted. Medical 
problems are stable. 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. 
 
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the powered pressure-reducing air mattress (E0277) provided 
on April 13, 2020. 
 
You asked the Plan to pay for the powered pressure-reducing air mattress. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says HCPCS code 
E0277-RR-KJ was not billed with an appropriate modifiers KX for any item to be covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say claim lines billed without a KX, GA, or GZ modifier will be rejected as missing information. 
 
 
 
 
 
 
We find that CPT code E0277 is not supported in the record. Specifically, CPT code E0277 has not been billed 
with the required modifier. Based on this information, we decided that Medicare rules for coverage of the 
powered pressure-reducing air mattress have not been met. Therefore, we decided that the Plan does not have 
to pay for the powered pressure-reducing air mattress (E0277) provided on April 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on June 1, 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 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that these services could be provided in-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 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 physician services provided on June 1, 2020 by an 
out of network (OON) provider
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on September 18, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without 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 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 medical services provided on September 18, 
2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Carboplatin dosing on days 1, 8, 15 every three weeks for the 
enrollee. 
 
You asked the Plan to pre-approve the dosage. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the dosing requested is higher than recommended. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 the dosage. Our reviewer says that the 
requested dosage of Carboplatin is medically reasonable and necessary. Our physician reviewer found the use 
of carboplatin in conjunction with paclitaxel is a standard regimen for mestatatic vulvar cancer. The dosing 
given is carboplatin AUC 5 day 1 with paclitaxel 80 mg/m2 days 1, 8, and 15 every 28 days which is a standard 
regiment. The service is reasonable and medically 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 dosage have been met. Therefore, we decided that the Plan has to pre-
approve Carboplatin dosing on days 1, 8, 15 every three weeks for the enrollee.  
 
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.