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

 
We decided that the Plan does not have to pay for hospital discharge day management services (99239) 
provided on November 14, 2019. 
 
You asked the Plan to pay for the hospital discharge day management services. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation 
submitted does not support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the documentation submitted 
does not support that 30 minutes of hospital discharge day management services were rendered on the billed 
date of service. Based on this information, we decided that Medicare rules for coverage of the hospital 
discharge day management services have not been met. Therefore, we decided that the Plan does not have to 
pay for hospital discharge day management services (99239) provided on November 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 25, 2019. 
 
You asked the Plan to pay for office visit. You say that you are appealing. The Plan denied your request. The 
Plan says the denial of payment for this service is correct, because a benefit is payable when the primary 
insurance payer's paid amount is less than the Medicare allowed amount, however in this case the primary 
carrier's payment is higher than the Medicare allowed amount. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. If the primary payer does not pay in full for the services, 
Medicare secondary benefits may be paid. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has confirmed 
that the primary insurance carrier's payment for this claim is higher than the Medicare allowable amount. 
Therefore, because the primary insurance carrier has already paid above the Medicare allowed amount for this 
claim, the Plan has no further amount to pay. Therefore, we decided that the Plan does not have to pay for an 
office visit provided on November 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services provided on January 25, 
2020. 
 
You asked the Plan to waive the copayment for specialist services. You say that you should not owe the 
copayment because you did not owe anything in the past. 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 $20 
copayment per specialist visit.  
 
You have been asked to pay a $20 copayment for specialist services. Specialist services fall 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 copayment for specialist services provided on January 25, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 5, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the billed codes 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. 
 
We find that CPT codes 81225-90-XS; 81226-90-XS; 81227-90-XS; 81230-90-XS; 81231-90-XS; 81240-90- 
XS; 81241-90-XS; 81328-90-XS; 81335-90-XS; 81355-90-XS; 81232-90-XS; 81283-90-XS; and 81408-90- 
XS are not supported in the medical record. Specifically, there is no laboratory report for the billed date of 
service. 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 March 5, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown provided on November 13, 2019. 
 
You asked the Plan to pay for the crown. You say that this should be paid because it was a broken front tooth 
that needed to be fixed. The Plan denied your request. The Plan says this service is 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 crown 
provided on November 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility services provided on July 17, 
2019. 
 
You asked the Plan to pay for the subsequent nursing facility services. The Plan denied your request. The Plan 
says the Plan requires utilization of network providers when possible and available, and requires authorization 
for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented. 
 
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 subsequent nursing facility services provided on July 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial observation care (99220) provided on March 31, 2020. 
 
You asked the Plan to pay for initial observation care. You say that this is the correct code for the service 
provided. The Plan denied your request. The Plan says an initial care code was already billed and paid for this 
date of 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. The rules also say that a physician may report 
only report one per diem E/M service on a single date of service. 
 
In this case, the CPT Code Manual definition of code 99220 is initial observation care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: 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 problem(s) requiring 
admission to outpatient hospital "observation status" are of high severity. Typically, 70 minutes are spent at the 
bedside and on the patient's hospital floor or unit.  
 
The definition of 99219 is initial observation care, per day, for the evaluation and management of a patient, 
which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical 
decision making of moderate 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 problem(s) requiring admission to outpatient hospital 
"observation status" are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit. 
 
We find that CPT code 99220 is not supported in the medical record. Specifically, the record shows that 99219, 
another per diem initial observation care code, was previously billed and paid for the same servicing provider 
on this date of service. Based on this information, we decided that Medicare rules for coverage of initial 
observation care have not been met. Therefore, we decided that the Plan does not have to pay for initial 
observation care (99220) provided on March 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services of a co-surgeon on an application of cranial 
tongs (20660-62) provided on October 8, 2019. 
 
You asked the Plan to pay for the services of a co-surgeon on an application of cranial tongs. You say that this 
should be covered. The Plan denied your request. The Plan says this service is not eligible for co-surgeon 
services. 
 
The Plan must follow Medicare rules. Medicare rules say that a value of 0 in the co-surgeon field of the 
Physician Fee Schedule Database indicates co-surgeons are not permitted for this procedure. 
 
We looked at the file and Medicare rules. The code for the service at issue has that a value of 0 in the co-
surgeon field of the Physician Fee Schedule Database. Based on this information, we decided that Medicare 
rules for coverage of the services of a co-surgeon on an application of cranial tongs have not been met. 
Therefore, we decided that the Plan does not have to pay for the services of a co-surgeon on an application of 
cranial tongs (20660-62) provided on October 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the biologic materials to aid in soft and osseous tissue 
regeneration and autogenous connective tissue graft procedure provided on February 11, 2020 by an OON 
provider. 
 
You asked the Plan to pay for the biologic materials to aid in soft and osseous tissue regeneration and 
autogenous connective tissue graft procedure. You say that you do not have a deductible with the Plan. You 
also say that these procedures should be completely covered, because they were done to improve your overall 
health and prevent complications from periodontal disease. The Plan denied your request. The Plan says your 
share was calculated correctly. The Plan also says that cost-sharing is a contractual obligation of the Plan and 
cannot be waived. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan is only obligated to pay 20% 
of the allowed amount. When services are rendered OON, you are responsible for paying all fees in excess of 
the maximum allowable. Therefore, we decided that the Plan does not have to pay for the biologic materials to 
aid in soft and osseous tissue regeneration and autogenous connective tissue graft procedure provided on 
February 11, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a hospital outpatient clinic visit (G0463) on 
February 17, 2020. 
 
You asked the Plan to waive the copayment for a hospital outpatient clinic visit. You say that you ought to be 
billed the copayment for a specialist visit. The Plan denied your request. The Plan says the correct copayment 
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 a $300 
copayment for each Medicare-covered outpatient hospital visit.  
 
You have been asked to pay a $120.56 copayment for a hospital outpatient clinic visit. A hospital outpatient 
clinic visit falls within the outpatient hospital services benefit category. This means that you have been asked to 
pay less than the full 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 hospital outpatient clinic visit (G0463) on February 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided on December 5, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for vision 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 the member's primary care physician did not refer these services.
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 vision services provided on December 5, 2019 by
an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on March 13, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says nonemergent,
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
laboratory services. 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 laboratory services provided on March 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat steroid injection 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says the information sent does not that there has been enough of other standard treatments in 
the past. 
 
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 injection. 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 documentation of a recent trial of conservative therapies, such as physical therapy, 
chiropractic therapy, or other physical medicine modalities. Therefore, the request does not meet the criteria. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat steroid injection
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided January 19, 2020 to January 
31, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically 
necessary. The Plan denied your request. The Plan says that rules for coverage were not met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably 
expected that the patient's necessary hospital care (including earlier emergency and/or observation care) would 
span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided January 19, 2020 to January 31, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the limited 
documentation provided, 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. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite provided on May 9, 2020 by an 
OON provider. 
 
You asked the Plan to pay for the resin-based composite. You say that you have previously had a claim paid for 
treatment received by this provider. The Plan denied your request. The Plan says the service was rendered by 
an OON provider. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the resin-
based composite provided on May 9, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on January 11, 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 the referring provider is also out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 January 11, 2020 
by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found based on the documentation 
provided, the enrollee does not have documented skilled nursing needs.  The enrollee does not have 
documented skilled therapy needs.  The enrollee is able to tend to mobility and activities of daily living with 
minimal assistance.  He is limited by his back pain.  The enrollee's care needs at this point are custodial and, as 
a practical matter, can be provided 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 admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).