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

 
We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating 
provider on March 25, 2020. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you used to only pay $16. The Plan 
denied your request. The Plan says the correct coinsurance has 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 20% 
coinsurance for Medicare Part B prescription drugs/in-network.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed 
amount is $637.50. The total amount you are being asked to pay is $127.50 ($637.50 x 20% = $127.50). An 
injection falls within the Medicare Part B prescription drugs/in-network 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 an injection provided by a participating provider on March 25, 
2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network 
provider on March 11, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for the services provided to the enrollee by an out-of-network provider on March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a colonoscopy (45380) provided on November 14, 2019. 
 
You asked the Plan to pay for the colonoscopy. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation that was sent shows that the 
provider is approved to participate with Medicare as a ?Clinic/Group Practice? not as an Ambulatory Surgical 
Center. 
 
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 code 45380 is not supported in the medical record. Specifically, the record indicates that this 
provider is approved to participate with Medicare as a clinic/group practice. It is inappropriate to bill these 
services as an ambulatory surgical center. Based on this information, we decided that Medicare rules for 
coverage of the colonoscopy have not been met. Therefore, we decided that the Plan does not have to pay for a 
colonoscopy (45380) provided on November 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (CPT 15956) provided to the enrollee on 
July 22, 2019. 
 
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 Current Procedural Terminology (CPT) code 15956 remains 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 15956 is "excision, trochanteric pressure ulcer, in 
preparation for muscle or myocutaneous flap or skin graft closure." 
 
We asked our 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 not supported by the medical records. Our coding reviewer found the procedure report does 
not include documentation to validate that an excision of trochanteric pressure ulcer, in preparation for muscle 
or myocutaneous flap or skin graft closure was rendered. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services (CPT 15956) provided to the enrollee on July 22, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy and wound care provided by a participating provider on August 9, 2019 to March 31, 2020.
You asked the Plan to waive the copayment for physical therapy and an outpatient surgery. You say that you think that the Plan should pay for this. 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 $40 copayment for outpatient rehabilitation services/in-network and a $300 copayment for outpatient surgery/in-network/outpatient hospital. You have been asked to pay a $40 copayment for physical therapy and $270 copayment which is less you're your copayment of $300 an outpatient surgery. The total amount you owe for physical therapy is $2,240 ($40 x 56 visits = $2,240). The total amount you owe for wound care is $810 ($270 x 3 surgeries = $810). The total amount you are being asked to pay is $3,050 ($2,240 + $810 = $3,050). Physical therapy falls within the outpatient rehabilitation services/in-network benefit category. Outpatient surgery falls within the outpatient surgery/in-network/outpatient hospital 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 physical therapy and wound care provided by a participating provider on August 9, 2019 to March 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes
(CPT Code 99239) provided December 6, 2019.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your
request. The Plan says the medical records do not support this 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 find that CPT code 99239 is not supported in the medical record. Specifically, the documentation submitted
did not include a hospital discharge day management note with a documented duration of time of 31 minutes or
more for the billed date of service of December 6, 2019; therefore, the billed service cannot be verified. The
submitted Discharge Summary is dated December 11, 2019. It is noted that multiple attempts were made to
contact the provider for additional information. Based on this information, we decided that Medicare rules for
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for
hospital discharge day management; more than 30 minutes (CPT Code 99239) provided December 6, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from October 15, 2019 
through October 17, 2019. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The 
Plan denied your request. The Plan says that the stay is not medically necessary. 
 
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 review has determined that 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 
department (ED) 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 from October 15, 2019 through October 17, 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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the restorative foundation for an indirect restoration (D2949) provided 
on March 2, 2020. 
 
You asked the Plan to pay for the restorative foundation for an indirect restoration. You say that tooth #28 does 
meet the criteria of large, active decay, fractured off portion of the tooth, or defective filling. The Plan denied 
your request. The Plan says that this service is a covered benefit, but you have exceeded the limits set in the 
subscriber agreement. 
 
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. The Plan covers the restorative 
foundation for an indirect restoration (D2949) when the services are medically necessary and reasonable. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan is required to submit all 
necessary information. The contract states that restorative foundation for an indirect restoration (D2949) is 
limited to once per tooth every five plan years. The record does not show that you received a restorative 
foundation for an indirect restoration (D2949) on tooth #28 over the last five years. Based on this information, 
we decided that the Plan's rules for coverage of the restorative foundation for an indirect restoration (D2949) 
have been met. Therefore, we decided that the Plan has to pay for the restorative foundation for an indirect 
restoration (D2949) provided on March 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound care provided by a participating 
provider on April 1, 2020. 
 
You asked the Plan to waive the copayment for wound care. You say that if you would have known it would 
this much you would not have had these services. The Plan denied your request. The Plan says the correct 
copayment has 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 $325 
copayment for outpatient facilities and surgical centers/outpatient surgery outpatient hospital.  
 
You have been asked to pay $303.92 which is less than your copayment amount of $325 for wound care. 
Wound care is considered an outpatient surgery; therefore, the correct copayment has been applied. Wound 
care falls within the outpatient facilities and surgical centers/outpatient surgery outpatient hospital 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 wound care provided by a participating 
provider on April 1, 2020.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan does not have to pay for the somatosensory testing, central motor evoked potential 
study (EVP), continuous intraoperative neurophysiology monitoring rendered on September 17, 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 the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for these services. Our reviewer says that the 
services were medically necessary. Our physician reviewer found the enrollee received spinal instrumentation 
surgery requiring pedicle screws or distraction and decompressive procedures on the spine for myelopathy or 
claudication where function of spinal cord or spinal nerves is at risk. These services are the standard of care for 
the enrollee's condition and were furnished in a manner readily consistent with indications/situations for which 
Medicare provides coverage. 
 
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 been met. Therefore, we decided that the Plan does not have 
to pay for the somatosensory testing, central motor evoked potential study (EVP), continuous intraoperative 
neurophysiology monitoring rendered on September 17, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for cranioplasty (62145) and repair of a cerebrospinal fluid leak (61618).
You asked the Plan to pay for the cranioplasty and fluid leak repair. 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 62415 is cranioplasty for skull defect with reparative brain surgery. The CPT Code Manual definition of code 61618 is secondary repair of dura for cerebrospinal fluid leak, anterior, middle or posterior cranial fossa following surgery of the skull base; by free tissue graft (e.g., pericranium, fascia, tensor fasciae latae, adipose tissue, homologous or synthetic grafts). 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 cranioplasty and fluid leak repair. Our reviewer says that CPT codes 61245 and 61618 do not meet criteria for billing or reimbursement consideration. Our reviewer found the operative records does not include a cranioplasty or secondary repair. 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 cranioplasty and fluid leak repair have not been met. Therefore, we decided that the Plan does not have to pay for cranioplasty (62145) and repair of a cerebrospinal fluid leak (61618).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on 
February 27, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that the service should have 
been billed as a screening colonoscopy. The Plan denied your request. The Plan says the copayment you are 
being charged is correct. 
 
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 $400 
copayment for each visit to an in-network outpatient hospital facility for Medicare-covered services. 
 
You have been asked to pay a $400 copayment for a diagnostic colonoscopy. A diagnostic colonoscopy 
received in an outpatient hospital setting falls within the outpatient hospital services benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on February 27, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the excision of benign tumor or cyst of maxilla (21048), midface 
reconstruction (21145), face bone graft (21210), and outpatient office visit (99213) provided on November 13, 
2019. 
 
You asked the Plan to pay for the excision, midface reconstruction, bone graft, and office visit. You say that the 
services provided by the surgeon is medically necessary for the enrollee's plan of surgery and treatment. The 
Plan denied your request. The Plan says that these services are not covered under the enrollee's plan. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the excision, midface reconstruction, bone 
graft, and office visit. Our reviewer says that the services meet coverage criteria. Our physician reviewer found 
these services provided by an oral surgeon meet the criteria stated in the EOC. 
 
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 excision, midface reconstruction, bone graft, and office visit have been met. 
Therefore, we decided that the Plan has to pay for the excision of benign tumor or cyst of maxilla (21048), 
midface reconstruction (21145), face bone graft (21210), and outpatient office visit (99213) provided on 
November 13, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the endoscopy from April 20, 2020 to April 
24, 2020. 
 
You asked the Plan to waive the copayment for the endoscopy. You say that you do not feel like you should 
have been charged for outpatient surgery. You say this was an inpatient stay. The Plan denied your request. The 
Plan says you have been charged 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 $75 
copayment for same day outpatient surgery in a freestanding ambulatory surgical center or outpatient hospital.  
 
You have been asked to pay a $75 copayment for the endoscopy. The endoscopy falls within the ?Outpatient 
hospital services? benefit category. The medical record shows that you were considered an outpatient during 
this hospital stay. 
 
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 from April 20, 2020 to April 24, 
2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CT, thorax; with contrast material(s) (71260) and CT, 
thoracic spine; without contrast material (72128) provided to the enrollee on August 6, 2019. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. The documentation submitted do 
not indicate that CT, thorax; with contrast material(s) was performed; therefore, the billed service cannot be 
verified. It is noted that multiple attempts were made to contact the provider for additional information. We 
have insufficient documentation to corroborate the services so we can confirm Medicare coverage has been 
met. 
 
The documentation submitted do not indicate that CT, thoracic spine; without contrast material was performed 
; therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the 
provider for additional information. We have insufficient documentation to corroborate the services so we can 
confirm Medicare coverage has been met.  
 
Therefore, we decided that the Plan does not have to pay for CT, thorax; with contrast material(s) (71260) and 
CT, thoracic spine; without contrast material (72128) provided to the enrollee on August 6, 2019.