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

We decided that the Plan does not have to pay for CPT codes 77002 and 20610 billed for date of service 
December 26, 2019. 
 
You asked the Plan to pay for CPT codes 77002 and 20610. You say that the services in dispute were billed 
appropriately. The Plan denied your request. The Plan says the CPT code 20610 was not submitted with an 
appropriate diagnosis code. The Plan says that CPT code 77002 was denied because it was not reported with an 
appropriate primary procedure code for the same 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 and with a diagnosis code that is the most precise 
and most fully explains the narrative description of the symptom or diagnosis. The rules also say that the 
information submitted by the provider must corroborate the documentation in the enrollee's medical records 
and confirm that Medicare coverage criteria have been met.  
 
We find that CPT code 20610 and add-on code 77002 are not supported by the diagnosis code billed. 
Specifically, primary generalized (osteo)arthritis is not an appropriate or allowable diagnosis code for CPT 
code 20610. A specific diagnosis code regarding the right hip would be needed to support 20610 with 77002. 
Based on this information, we decided that Medicare rules for coverage of CPT codes 77002 and 20610 have 
not been met. Therefore, we decided that the Plan does not have to pay for CPT codes 77002 and 20610 billed 
for date of service December 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for spinal x-rays (72114 and 72052) provided on February 6, 
2020. 
 
You asked the Plan to pay for the spinal x-rays. 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 services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 72114 is radiologic examination, spine, lumbosacral; 
complete, including bending views, minimum of 6 views. 
 
The CPT Code Manual definition of code 72052 is radiologic examination, spine, cervical; 6 or more views. 
 
 
We asked our coder 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 spinal x-rays. Our reviewer says that CPT code 72114 
does not meet criteria for billing or reimbursement consideration.The number of views taken is not documented 
in the radiology report submitted, therefore this code cannot be verified. Our reviewer found CPT code 72052 
does not meet criteria for billing or reimbursement consideration. The record does not include documentation 
of 6 or more views and findings.  Therefore, this code cannot be verified. 
 
 
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 spinal x-rays have not been met. Therefore, we decided that the Plan does 
not have to pay for spinal x-rays (72114 and 72052) provided on February 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride (D1206) and the pulpal 
debridement (D3221) provided from March 11, 2020, to March 12, 2020 by the out of network dentist. 
 
You asked the Plan to pay for the fluoride application and pulpal debridement. You say that you have enrolled 
in the dental rider. You say that you are having issues getting coverage for the out of network dental services 
you received. You also say that the out of network dental services you received in April were covered. The 
Plan denied your request. The Plan says the topical application of fluoride is not listed as a covered service. 
The Plan says pulpal debridement is not listed as a covered service either. 
 
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 fluoride application and pulpal 
debridement are not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pay for the topical application of fluoride (D1206) and the pulpal debridement (D3221) provided from 
March 11, 2020, to March 12, 2020 by the out of network dentist.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided by an out-of-network provider on 
April 23, 2019. 
 
You asked the Plan to pay for physical therapy. You say that you are appealing unpaid bills for services 
recommended by your primary care physician. The Plan denied your request. The Plan says the service requires 
prior authorization and there is insufficient information to determine medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must submit sufficient information 
to confirm that coverage criteria have been met and to determine whether payment is due.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy have not been met. Therefore, we decided that the Plan does not have to pay for 
physical therapy provided by an out-of-network provider on April 23, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided by an out-of-network provider on 
April 18, 2019. 
 
You asked the Plan to pay for physical therapy. You say that you are appealing unpaid bills for services 
recommended by your primary care physician. The Plan denied your request. The Plan says the service requires 
prior authorization and there is insufficient information to determine medical necessity. 

The Plan must follow Medicare rules. Medicare rules say that the provider must submit sufficient information 
to confirm that coverage criteria have been met and to determine whether payment is due. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy have not been met. Therefore, we decided that the Plan does not have to pay for 
physical therapy provided by an out-of-network provider on April 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), additional 
intraoral periapical x-ray (D0230), palliative (emergency) treatment of dental pain (D9110), and complete 
maxillary denture (D5110) provided on May 1, 2020, and May 27, 2020. 
 
You asked the Plan to pay for the intraoral periapical x-rays, emergency treatment, and complete maxillary 
denture. You say that these services were provided due to an accident. The Plan denied your request. The Plan 
says these services are not covered by the Plan. 
 
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. The Plan did not indicate that you purchased an optional supplemental 
package prior to these dates of service.  
 
Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), 
additional intraoral periapical x-ray (D0230), palliative (emergency) treatment of dental pain (D9110), and 
complete maxillary denture (D5110) provided on May 1, 2020, and May 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat (E0244). 
 
You asked the Plan to pre-approve a raised toilet seat. You say that you need this because your current 
commode is not wide enough. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate for the enrolee, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat (E0244).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient psychiatric care provided from February 24, 2020, to 
March 2, 2020. 
 
You asked the Plan to pay for inpatient psychiatric hospital services. You say that the enrollee reported active 
suicidal ideation. The Plan denied your request. The Plan says that the enrollee could have safely been treated 
in an outpatient program. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. Our 
physician reviewer found this enrollee did appear to require inpatient mental health treatment as she was a 
danger to herself, but not others without any aggressive behaviors. Active treatment was taking place. It did 
appear that the services were reasonably expected to improve the enrollee's condition, or for the purpose of 
diagnosis. The records were supervised and evaluated by a physician. Based upon review the records provided, 
the enrollee's care was medically necessary as she was shown to be a danger to herself 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pay for the inpatient psychiatric care provided from February 24, 2020, to March 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the albumin and creatinine testing provided on December 9, 
2019. 
 
You asked the Plan to pay for the albumin and creatinine testing. You say that the records support the need for 
this these services. The Plan denied your request. The Plan says the record does not include an order for the 
albumin or creatinine testing. All other testing was approved for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by a 
treating provider and the intent is clear in the record. 
 
In this case, no formal order form for lab testing is included; however, the visit note does clearly support a plan 
to provide certain tests, but albumin and creatinine are not listed in the note. Therefore, we decided that the 
Plan does not have to pay for the albumin and creatinine testing provided on December 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for EKG services received on December 16 to 
December 17, 2019. 
 
You asked the Plan to waive the coinsurance for EKG services. You say that you were informed by a 
representative of the Plan that you would only be responsible for a $250 copayment. 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 5% 
coinsurance for each outpatient hospital visit for outpatient diagnostic tests.  
 
You have been asked to pay $945.47, or 5% coinsurance of the Plan-allowed amount $18,909.39, for EKG 
services. EKG services fall within the "Outpatient diagnostic tests, therapeutic services and supplies" 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 EKG services received on December 16 to 
December 17, 2019.  
 
Your complaint about receiving erroneous or misleading information about your cost-sharing responsibility 
from a representative of the Plan 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT, heart, without contrast material, with quantitative 
evaluation of coronary calcium (CPT Code 75571). 
 
You asked the Plan to pre-approve the CT scan. You say that the CT scan is necessary. The Plan denied your 
request. The Plan says the CT is not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 the CT scan. Our physician reviewer 
found based on the records you have increased coronary risk, moderate coronary calcium on chest CT scan and 
no documented symptoms concerning for coronary ischemia. In this setting, coronary CT angiography is not 
recommended and has not been shown to improve cardiac outcome incremental to that achievable based on 
treatment guided by standard clinical risk profiling and basic lipid analysis alone. The records do not support 
the medical necessity for the procedure in appeal. Coverage criteria are not met since there are no documented 
covered indications for the procedure. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve CT, heart, without contrast material, with quantitative evaluation of coronary calcium 
(CPT Code 75571).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan. 
 
You asked the Plan to pre-approve a CT scan. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 CT scan. Our reviewer says that the 
documentation does not support that the requested CT scan is medically reasonable or necessary. Our physician 
reviewer found your 10 year risk for cardiovascular disease is high at 36%. You have hypertension and 
hyperlipidemia and a mildly positive stress nuclear test for ischemia which is being managed medically 
suggesting established, but sub-clinical Coronary Artery Disease (CAD). You should therefore be treated with 
statin medication based on ACC/AHA guidelines and this has been recommended. Coronary CT scanning in 
this instance, even if calcium score is low, would not determine the need for statin therapy. A low calcium 
score would not obviate the need to treat your lipids to goal using both lifestyle modification and statin therapy. 
Therefore, you do not meet criteria for the requested 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 a CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a CT scan.
Appeal type: Testing
Decision: Partially Favorable

We decided that the Plan has to reduce the coinsurance for an outpatient surgery and observation services. We 
decided that the Plan does not have to waive the coinsurance for an outpatient surgery and observation services.  
 
You asked the Plan to waive the coinsurance for an outpatient surgery and observation services. You say that 
you thought this was in-network The Plan says that the correct coinsurance has been applied. 
 
We decided that the Plan has to reduce the coinsurance for an outpatient surgery and observation 
services.  
 
You cannot be asked to pay more than a 20% coinsurance of the allowed amount for these services. The total 
allowed amount is $1,012.48. The total amount that should be paid is $202.50 ($1,012.48 x 20% = $202.50). 
 
We also decided that the Plan does not have to waive the coinsurance for an outpatient surgery and 
observation services. 
 
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 an outpatient surgery and observation services. Therefore, we decided that the Plan does not 
have to waive the coinsurance for an outpatient surgery and observation services. 
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services rendered on August 13, 2018. 
 
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 claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for these services was not filed until May 12, 2020. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the emergency room services rendered on August 13, 2018.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient services provided from March 24, 2020 to April 11, 2020. 
 
You asked the Plan to pay for the inpatient services. You say that the services were billed with the correct DRG 
code. The Plan denied your request. The Plan says that the claim is missing a RUG code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG. 
 
We find that the inpatient billing is supported in the medical record. Specifically, the inpatient services were 
billed with a valid DRG code. A required RUG code is only required for skilled nursing facility payments. This 
case supports that inpatient services were provided. Based on this information, we decided that Medicare rules 
for coverage of the inpatient services have been met. Therefore, we decided that the Plan has to pay for the 
inpatient services provided from March 24, 2020 to April 11, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia injections. 
 
You asked the Plan to pre-approve Prolia. You say that the enrollee is not a candidate for Reclast because she 
has already taken bisphosphonates for 5 years. You also say that Prolia is the most effective option. The Plan 
denied your request. The Plan says the documentation did not support the criteria. 
 
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 Prolia 
injections are not medically reasonable and necessary. Our physician reviewer found the enrollee has not tried 
and failed the required drug. The enrollee has continued osteoporosis and has had five years of Alendronate 
therapy. Our reviewer found that the literature states that women at continued high risk should continue to take 
oral bisphosphonates up to 10 years or intravenous therapy up to 6 years.  
 
Our physician reviewer also found that there is no documentation provided indicating that the Plan's required 
drug(s) would likely be less effective and/or likely 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 Prolia injections.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation services. 
 
You asked the Plan to pre-approve the requested services. You say that you are in severe pain and unable to do 
your daily living activities. The Plan denied your request. The Plan says radiofrequency ablation for pain 
management related to sacroiliitis has not been shown to provide a clear long-term benefit over standard 
treatment. 
 
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 requested services. Our physician 
reviewer found that you have a diagnosis of left sacroiliac joint pain due to sacroiliitis and sacral spondylosis. 
This request is for Coolief radio frequency ablation to the nerves innervating the left sacroiliac joint. This is a 
non-thermal radio frequency denervation. Small clinical trials evaluating radio frequency denervation for facet 
joint pain, discogenic low back pain, radicular pain, and chronic sacroiliac joint pain have generally shown no 
effectiveness or modest, short-term, benefit. Therefore, this procedure is not medically necessary and 
reasonable. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radio frequency ablation services.