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

 
We decided that the Plan does not have to pay for the endodontic therapy premolar tooth. 
 
You asked the Plan to pay for the endodontic therapy. You say that the Plan pre-approved coverage of the 
service, therefore you should not owe anything. The Plan denied your request. The Plan says your benefit has a 
$1,000 annual limit and you have reached this limit, therefore the correct cost share applied to the claim. 
 
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 exceed 
those covered under this benefit. Although the Plan pre-approved coverage of the endodontic therapy, cost 
sharing rules still apply to the claim. The Plan contract states that after the annual maximum benefit limit of 
$1,000 is exhausted then any remaining charges are your responsibility. Therefore, we decided that the Plan 
does not have to pay for the endodontic therapy premolar tooth.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a posterior interspinous decompression spacer 
procedure. 
 
You asked the Plan to pre-approve Insertion of interlaminar/interspinous process stabilization/distraction 
device, without open decompression or fusion, including image guidance when performed, lumbar; single level 
(22869). You say that this procedure would provide significant clinical and quality of life benefits for the 
enrollee. The Plan denied your request. The Plan says a review of the current medical literature indicates that 
this service is considered experimental and investigational. 
 
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 Insertion of interlaminar/interspinous 
process stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; single level (22869). Our reviewer says that the requested services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the spacer is experimental at 
this time, 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 Insertion of interlaminar/interspinous process stabilization/distraction device, 
without open decompression or fusion, including image guidance when performed, lumbar; single level 
(22869) have not been met. Therefore, we decided that the Plan does not have to pre-approve a posterior 
interspinous decompression spacer procedure.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for surgical pathology services (CPT 88305) provided to the enrollee.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says that a global charge was billed and reimbursed to another provider; this is a duplicate charge.

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 88305 is "Level IV - Surgical pathology, gross and microscopic examination."

We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were supported by the medical records. Our coding reviewer found the documentation submitted includes documentation from CDX only. There is no documentation submitted to confirm CPT 88305 was billed by a provider other than CDX. Therefore, this claim cannot be verified as duplicate billing.

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 been met. Therefore, we decided that the Plan has to pay for surgical pathology services (CPT 88305) provided to 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.
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 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 IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 health plan's denial should be upheld. The enrollee does not require the intensity 
of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of 
rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of 
care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid check you received on October 15, 2020. 
 
You asked the Plan to pay for the hearing aid check. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
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 provided by a TruHearing provider. 
 
We looked at the file and the Plan's rules. The records show that you were provided the hearing aid services by 
an out-of-network provider. The Plan does not cover these services when provided by an out-of-network 
provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aid check have 
not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid check you received 
on October 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided on November 5, 
2020. 
 
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like reconsideration because 
this equipment is medically necessary. The Plan denied your request. The Plan says Medicare does not allow 
unsolicited contact with the member. 
 
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 lumbar-sacral orthosis. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the clinical documentation in the case file does not support that the enrollee in this 
case requires a lumbar-sacral orthosis. 
 
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 lumbar-sacral orthosis have not been met. Therefore, we decided that the 
Plan does not have to pay for lumbar-sacral orthosis (L0650) provided on November 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the after-cataract laser surgery.

You asked the Plan to waive the copayment for the after-cataract surgery. You say that you were told you would not have a copayment. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $225 copayment for all other Ambulatory Surgical Center (ASC) services. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $225 copayment for the after-cataract laser surgery at an ambulatory surgical center.

You have been asked to pay a $218.69 copayment for the after-cataract surgery. The after-cataract surgery 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 copayment for the after-cataract laser surgery.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81120, 81121, 81201, 81235, 
81270, 81775, 81310, 81311, 81173, 81172, 81314, 81321, 81404, 81405, and 81406. provided on November 
20, 2020. 
 
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 billed are not payable. 
 
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 81120, 81121, 81201, 81235, 81270, 81775, 81310, 81311, 81173, 81172, 81314, 
81321, 81404, 81405, and 81406. are not supported in the medical record. Specifically, the services provided 
should be billed with code 81479. In addition, the appropriate DEX Z code identifier should be entered 
adjacent to the code in the comment/narrative field. 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 81120, 81121, 81201, 81235, 81270, 81775, 81310, 81311, 81173, 
81172, 81314, 81321, 81404, 81405, and 81406. provided on November 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided by a participating 
provider on September 29, 2020, to October 1, 2020. 
 
You asked the Plan to waive the copayment for an office visit. You say that you say that the hospital was full, 
and it wasn't your fault. The Plan denied your request. The Plan says the correct copayments have been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for physician/practitioner services/specialist visit.  
 
You have been asked to pay a $35 copayment for an office visit. The total amount you are being asked to pay is 
$89.96 ($35 + $27.48 + $27.48 = $89.96). The correct copayments have been applied to the services that were 
provided. An office visit falls within the physician/practitioner services/specialist visit 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 office visit provided by a participating provider on 
September 29, 2020, to October 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 enrollee has gotten slower and weaker. The enrollee is not taking medications as 
prescribed/intended. The documentation does not support that the enrollee requires an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the 
enrollee requires an intensive rehabilitation therapy program. The enrollee's care needs can be met at a lower 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy provided on November 20, 
2020. 
 
You asked the Plan to waive the copayment for the endoscopy. You say that you should not have a copayment, 
but you are being billed by the provider. The Plan denied your request. The Plan says the copayment applied 
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 $295 
copayment for all other outpatient services including observation and outpatient surgical services not provided 
in an ambulatory surgical center. 
 
You have been asked to pay a $295 copayment for the endoscopy. The endoscopy 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 copayment for the endoscopy provided on November 20, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) and a knee orthosis with 
suspension sleeve (L1833, L2397) provided to the enrollee on October 13, 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 lumbar-sacral orthosis 
(L0648) and a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on October 13, 
2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for physician services (CPT 99358) provided to the enrollee.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says that it is not appropriate to use this code when it is not related to a face-to-face service.

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 99358 is "prolonged evaluation and management before and/or after direct patient care; first hour."

We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were supported by the medical records. Our coding reviewer found the provider performed a virtual visit with the enrollee, with documentation of spending 31 minutes non face to face time reviewing charts and coordinating care. Per CMS-1744-IF (page 122 and 123) changes due to the COVID-19 pandemic, prolonged service codes, 99358-99359 can be billed with telephone services. Therefore, this service should be covered.

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 been met. Therefore, we decided that the Plan has to pay for physician services (CPT 99358) provided to 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan (93971) provided on July 25, 2019. 
 
You asked the Plan to pay for the duplex scan. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the clinical records do not provide explanation 
for multiple duplex scans to the left lower extremity. 
 
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 duplex scan. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no clinical documentation supporting multiple studies (or additional studies) of the 
same lower extremity over such a short period of time. 
 
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 duplex scan have not been met. Therefore, we decided that the Plan does not 
have to pay for the duplex scan (93971) provided on July 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pharmacogenomic test.

You asked the Plan to pay for the testing services. You say that the test has been shown to decrease healthcare utilization. The Plan denied your request. The Plan says a panel constitutes a single procedural service.

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 looked at the file and the rules. If a single procedure is performed, only one CPT code with one unit of service may be reported for the procedure. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the pharmacogenomic test.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion interspinous device for the enrollee 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says that this has not been shown to be safe and effective. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The spacer is 
experimental. More research is needed to show safety and efficacy of vertiflex device. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for these services. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a Vertiflex Superion interspinous device for the enrollee