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

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on July 16, 2021. 
 
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 the requested service codes are not substantiated by the clinical documentation in the medical 
records submitted for review. 
 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 the denied codes is: 
 
CPT 22614: 
 
Arthrodesis, posterior or posterolateral technique, single interspace; each additional interspace (List separately 
in addition to code for primary procedure) 
 
CPT 22830: 
 
Exploration of spinal fusion 
 
CPT 61783: 
 
Stereotactic computer-assisted (navigational) procedure; spinal (List separately in addition to code for primary 
procedure) 
 
CPT 63045: 
 
Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda 
equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; cervical 
 
In this case, we have confirmed that CPT 22830 is a Column II code to the Column I code 22610, and that CPT 
61783 is a Column II code to the Column I code 63045. An appropriate modifier was not used in this case to 
bypass the edit.  
 
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 CPT 63045 and CPT 22613. Our reviewer says that these 
codes were not supported by the medical record. Our reviewer found there is no documentation in the medical 
records of the denied codes. They are not described in the record. 
 
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 provided to the enrollee on July 16, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services (90837) provided on September 
16, 2021, through September 30, 2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says this provider is not eligible for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that licensed professional counselors are not eligible 
to enroll in Medicare. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, the records indicate that this provider 
is a licensed professional counselor. Licensed professional counselors are not eligible to enroll in Medicare or 
eligible for Medicare payment. Therefore, we decided that the Plan does not have to pay for the psychotherapy 
services (90837) provided on September 16, 2021, through September 30, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on July 26, 2021. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you understand the office visit 
copayment but disagree with the additional charges. 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 $155 
copayment for radiological diagnostic services, including ultrasounds.  
 
You have been asked to pay the allowed amount of $97.81, which is less than the $155 copayment for an 
ultrasound. An ultrasound falls within the outpatient diagnostic tests and 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 copayment for an ultrasound provided on July 
26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an emergency room visit, and an inpatient 
hospital stay from January 19, 2021, to January 23, 2021. 
 
You asked the Plan to waive the copayments for an emergency room visit, and inpatient hospital stay. You say 
that you would like to dispute the copayments applied. The Plan denied your request. The Plan says the proper 
copayments were applied for the services provided. 
  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment per emergency room visit and the copayment is not waived if admitted to inpatient hospital. 
 
Your contract with the Plan also clearly says that you must pay a $225 copayment per day for days 1-6 per 
inpatient hospital stay admission. The total copayment amount is $900 ($225 copayment per day x 4 days) for 
the inpatient hospital stay. 
 
You have been asked to pay a $90 copayment for an emergency room visit and a $900 copayment for an 
inpatient hospital stay. An emergency room visit falls within the Emergency care benefit category. The 
inpatient hospital stay falls within the Inpatient hospital care 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 copayments for an emergency room visit, and an inpatient hospital stay from January 19, 2021, to 
January 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bi-level positive airway pressure device (BiPAP) and 
related supplies provided on June 29, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for a BiPAP and related supplies. You say that the items at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for out-of-network 
care have not been met. 
 
 
 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 had network providers 
available who could have provided 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 a bi-level positive airway pressure device (BiPAP) 
and related supplies provided on June 29, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for podiatry services provided on September 
28, 2021. 
 
You asked the Plan to waive the copayment for podiatry services. You say that your benefits say that you 
should only owe a $15 copayment for specialist services. 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 $25 
copayment for podiatry services.  
 
 
 
 
 
 
 You have been asked to pay a $25 copayment for podiatry services. Podiatry services fall within the podiatry 
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 podiatry services provided 
on September 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99202) provided October 12, 
2021. 
 
You asked the Plan to pay for the chiropractor services. You say that you talked with the provider and they told 
you that you did not have a balance with them. The Plan denied your request. The Plan says this service is not 
covered when rendered by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the outpatient office visit (99202) provided October 12, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an office visit provided on October 7, 2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that the services should be covered as 
you were told there would be no copayments. The Plan denied your request. The Plan says that they have paid 
their share and has confirmed with the provider that they will submit the claim to Medicaid to cover the 
difference. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $0 copayment for Physician/Practitioner services, 
including doctor's office visits.  
 
The Plan says you must pay a $97.26 copayment for an office visit. Based on the Plan contract, however, you 
cannot be asked to pay more than a $0 copayment for the office visit. Therefore, we decided that the Plan has to 
waive the copayment for an office visit provided on October 7, 2021.  
 
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 waive the copayment for an inpatient hospital stay from October 29 
to November 4, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that the charge is much 
more than you can handle. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $295 copayment for each day of days 1 to 6 of inpatient hospital care.  
 
 
 
 The enrollee has been asked to pay $1,475, or a $295 copayment for each day of a 5-day inpatient hospital stay. 
An inpatient hospital stay falls within the "Inpatient hospital care" benefit category. This means that the 
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Health plans are not required to 
waive this cost sharing when there is dissatisfaction with the quality of care received. Therefore, we decided 
that the Plan does not have to waive the copayment for an inpatient hospital stay from October 29 to November 
4, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the aspirin and 2 clopidogrel provided in an outpatient 
setting on September 30, 2021. 
 
You asked the Plan to pay for the self-administered drugs. You say that you were at the hospital for testing. 
You also say that you were not given any drugs to take home. The Plan denied your request. The Plan says the 
drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a 
Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under 
Medicare Part B.  
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the aspirin and 2 clopidogrel 
provided in an outpatient setting on September 30, 2021.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a seat lift mechanism (E0627) provided on August 11, 2021. 
 
You asked the Plan to pay for a seat lift mechanism. You say that you did not know at the time of purchase that 
the item at issue could be covered by the Plan. The Plan denied your request. The Plan says rules for payment 
have not been met because the provider at issue is not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a seat lift mechanism (E0627) provided 
on August 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration because 
the requested LTACH services are medically necessary. The Plan denied your request. The Plan says the 
member does not meet Medicare criteria for coverage of the LTACH services. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where she is 
currently receiving care. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment (98941) provided on 
August 18, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chiropractic services. You say that you had asked about what was required to 
visit a chiropractor and you were told a referral was not required. You should not incur the cost of two 
treatments in putting trust on the directive of your doctor. The Plan denied your request. The Plan says a 
referral must be obtained prior to receiving services. Prior authorization was required. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that prior authorization is required for chiropractic services. 
 
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 chiropractic 
manipulative treatment (98941) provided on August 18, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an autogenous connective tissue graft procedure 
(D4283) and comprehensive periodontal evaluation (D0180). 
 
You asked the Plan to pre-approve the autogenous connective tissue graft procedure and comprehensive 
periodontal evaluation. You say that you would like to appeal these services. The Plan denied your request. The 
Plan says autogenous connective tissue graft procedure is not a covered service. The Plan also says that the 
comprehensive periodontal evaluation exceeds the frequency limitation under your plan. 
 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, autogenous connective tissue graft 
procedure (D4283) is not among those covered under this benefit. The contract says that comprehensive oral 
exams are limited to once every 36 months. The record shows that you received a comprehensive periodontal 
evaluation on June 4, 2021 and your comprehensive oral exams benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pre-approve an autogenous connective tissue graft procedure (D4283) 
and comprehensive periodontal evaluation (D0180).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a specialist office visit. You say that you cannot make an early appointment 
with the Plan's in-network provider. The Plan denied your request. The Plan says there are plenty of in-network 
providers that provide the same quality of service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tyvaso for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is denied as a benefit exclusion. 
 
  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tyvaso for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection, diagnostic or therapeutic agent, paravertebral 
facet joint with image guidance, lumbar or sacral; second level (64494) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that records show that the enrollee did not receive relief from a 
previous diagnostic block at this spinal level. 
 
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 enrollee has a 
history of chronic low back pain. The pain is in the left lower back and is rated seven out of 10 in severity. The 
pain is aggravated by standing, walking, and leaning over. Alleviating factors include rest and medication. 
Treatment has included medical therapy, physical therapy, status post left L4-L5, L5-S1 facet blocks on 
December 1, 2021, and status post lumbar epidural steroid injection on January 14, 2022. The initial diagnostic 
facet injection provided no relief. Our physician reviewer found that the enrollee's condition does not meet 
criteria for coverage of 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 injection, diagnostic or therapeutic agent, paravertebral facet joint with image guidance, 
lumbar or sacral; second level (64494) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lightweight wheelchair. 
 
You asked the Plan to pay for a wheelchair. You say that the enrollee's wheelchair was misplaced. The Plan 
denied your request. The Plan says the enrollee does not have the benefits for the requested wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that durable medical equipment is only covered under 
certain medical indications.  
 
We looked at the file, and Medicare rules. The records show that the enrollee last received a wheelchair in 
2020. The enrollee is not eligible for a wheelchair until 5 years since the prior wheelchair was provided. Based 
on this information, we decided that Medicare rules for coverage of a wheelchair have not been met. Therefore, 
we decided that the Plan does not have to pay for a lightweight wheelchair.