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

 
We decided that the Plan does not have to waive the copayment for outpatient surgery on April 22, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says the cost sharing 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 $395 
copayment for each Medicare-covered outpatient hospital visit.  
 
You have been asked to pay a $395 copayment for outpatient surgery. Outpatient surgery 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 outpatient surgery on April 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Bone marrow aspiration for bone grafting, spine surgery 
(20939). 
 
You asked the Plan to pre-approve the procedure. You say that this enrollee is in severe pain and the denial is 
only worsening the enrollee's quality of life and postponing appropriate treatment. The Plan denied your 
request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of spinal 
fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Bone marrow aspiration for bone grafting, spine surgery (20939).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 75743, 75820 and 99153 billed for date of 
service March 4, 2022.  
You asked the Plan to pay for the serov9ices. You say that the enrollee had multiple exams on this date and 
these services were reported correctly The Plan denied your request. The Plan says these services were not 
billed in accordance with Medicare rules. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 serov9ices Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
procedure report describes bilateral pulmonary angiography in addition to an intervention performed.  In this 
case, interventional procedures include angiograms and venograms. Therefore, this procedure (CPT 75743) 
reported with modifier -59 cannot be verified. In terms of CPT 75820, the procedure report does not include 
documentation of a unilateral extremity venography, and therefore this procedure code cannot be verified.  Was 
unable to cite report as this procedure was not found in operative report. 
 
We looked at this physician's review, the file, and Medicare rules. Our coder found that the records do not 
support CPT 75743 and CPT 75820. Additionally, CPT 99153 is not supported, as it has a PC/TC indicator of 
3, meaning TC only. The services were billed with Place of Service 21, for inpatient hospital. Therefore, the 
services were not supported. Based on this information, we decided that Medicare rules for coverage of the 
serov9ices have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
75743, 75820 and 99153 billed for date of service March 4, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to not recoup the payments for cardiology services provided from December 16, 
2020, t July 6, 2021. 
 
You asked the Plan to not recoup the payments for the cardiology services. You say that these services were 
medically necessary and not experimental/investigational. Therefore, it is not appropriate for the Plan to try to 
recoup monies for these services. The Plan denied your request. The Plan says that their policy excludes 
coverage for these services because they are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, in the very sparse case file that the Plan sent to us, it appears as 
though the Plan's denial is because these services were not medically necessary and experimental/ 
investigational.  However, the Plan has provided no citations to or copies of any rule or policy upon which this 
determination was based.  The Plan has provided no medical records.  The Plan has provided no evidence that 
anyone even reviewed your request to determine the medical appropriateness of the services rendered.  The 
burden is on the Plan to prove that its denial (or, in this case, its recoupment) is justified.  Without any of the 
aforementioned documentation, the Plan has not met this burden. Therefore, we decided that the Plan has to not 
recoup the payments for cardiology services provided from December 16, 2020, t July 6, 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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan does not have to pre-approve crowns (D2750) for teeth # 21 and 28. 
 
You asked the Plan to pre-approve the dental services. You say that the requested crowns are necessary. The 
Plan denied your request. The Plan says crowns for teeth # 21 and 28 are not medically necessary. 
 
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. The Plan covers the dental 
services when the services are medically necessary and reasonable. 
 
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 dental services. Our reviewer says 
that the crowns for teeth # 21 and 28 are medically necessary. Our physician reviewer found the documentation 
does show that the root canal filling in tooth # 21 appears short of the apex. The reviewer found that the canal 
appears calcified apical to the fill and no pathology is apparent at the root apex. The reviewer found that the fill 
in tooth # 28 appears adequate. therefore, the reviewer found that the requested crown restorations are 
medically reasonable and necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan does not 
have to pre-approve crowns (D2750) for teeth # 21 and 28.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hospital services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the hospital services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they are 
non-emergent and can be provided in-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 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 
hospital services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the low-level laser treatment (S8948) and 
the massage therapy (97124) provided on April 4, 2022. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services at 
issue are not covered under your contractual policy or by Medicare. 
 
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. Additionally, the Plan covers a chiropractic initial 
evaluation once per calendar year.  
 
The records show that the services at issue are not covered by the Plan or by Medicare. Therefore, we decided 
that the Plan does not have to issue reimbursement for the low-level laser treatment (S8948) and the massage 
therapy (97124) provided on April 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pelvis/hip joint surgery (27299) provided on January 24, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the pelvis/hip joint surgery. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
  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 pelvis/hip joint surgery (27299) provided on 
January 24, 2022 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for retina eye surgery provided on March 23, 2022. 
 
You asked the Plan to waive the cost for retina eye surgery. You say that if you had known the total cost of this 
procedure was going to be a total of $1,120.20, you would not have had it done. You also inquired from 
multiple sources how much this surgery would cost, and never got an answer. The Plan denied your request. 
The Plan says you were charged this cost sharing correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $450 
deductible, followed by a 10% coinsurance after meeting said deductible for outpatient surgery.  
 
You have been asked to pay $400.86 of your $450 deductible, followed by $719.34 which is your 10% 
coinsurance after meeting said deductible for retina eye surgery ($400.86 + $719.34 = $1,120.20). Retina eye 
surgery falls within the outpatient surgery 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 cost for retina eye surgery provided on March 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 28, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a CT scan provided on April 21, 2022. 
 
You asked the Plan to reduce the copayment for a CT scan. You say that your copayment should only be $180. 
The Plan denied your request. The Plan says that the cost share was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for in-network advanced imaging services.  
 
 
 
 
 
 
 
 
 You have been asked to pay a $275 copayment for a CT scan. A CT scan 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 reduce the copayment for a CT scan provided on 
April 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a labial veneer (D2960), pulp cap (D3120), and 2 lower 
partial dentures with flexible base (D5226). 
 
You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied 
your request. The Plan says the requested services are not listed as covered services. 
 
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 requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a labial 
veneer (D2960), pulp cap (D3120), and 2 lower partial dentures with flexible base (D5226).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on April 12, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing 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 $35 
copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse 
practitioner or physicians assistant or other non-physician health care professionals in a specialists office (as 
permitted under Medicare rules). Covered services include consultation, diagnosis, and treatment by a 
specialist 
 
 
 
 You have been asked to pay a $35 copayment for office visit. Office visits 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 office visit on April 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Hepatitis A vaccination you received on March 4, 2022. 
 
You asked the Plan to pay for the Hepatitis A vaccination. You did not provide a specific argument with your 
appeal request. The Plan denied your request. The Plan says the Hepatitis A vaccine is not covered under your 
medical benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Hepatitis A 
vaccination. The Plan follows the same rules. Records do not show that you have been injured or directly 
exposed to any illness related to the Hepatitis A vaccination. Therefore, we decided that the Plan does not have 
to pay for the Hepatitis A vaccination you received on March 4, 2022.  
 
Benefits for the Hepatitis A vaccination 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services on February 03, 
2021. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost sharing 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 $90 
copayment for emergency care. Cost sharing is waived if you are admitted to the hospital. Emergency care 
refers to services that are furnished by a provider qualified to furnish emergency services and needed to 
evaluate or stabilize an emergency medical condition.  
 
 
 
 You have been asked to pay a $90 copayment for emergency room services. Emergency room services fall 
within the Emergency 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 copayment for emergency 
room services on February 03, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing (81455) provided on April 21, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory testing. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
  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 laboratory testing (81455) provided on April 21, 
2022 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on October 27, 
2021. 
 
You asked the Plan to waive the copayment for physical therapy. You say that this should only be a $20 
copayment. The Plan denied your request. The Plan says the copayment applied 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 $150 
copayment per visit for all other services furnished at a hospital outpatient facility.  
 
 
 You have been asked to pay $63.90 which is less than the standard $150 copayment for physical therapy. 
Physical therapy at a hospital outpatient facility 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 physical therapy provided on October 27, 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 the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does
not meet criteria.

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 there is no documentation provided indicating medical necessity for admission to a
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for
the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient
basis.

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.