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

 
We decided that the Plan does not have to pay for procedure code 81161 billed for date of service November 
29, 2021. 
 You asked the Plan to pay for procedure code 81161. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 81161 is bundled into payment for code 81413. 
 
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, we have confirmed that code 81161 
is a column II code to column I code 81413. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 81161 billed for date of service November 29, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on April 7, 2022. 
 
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 procedure code 11721 is not separately payable. 
 
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.   
 
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, the records do not support that procedure code 11721 was a separate and distinct 
procedural service from code 11750. Based on this information, we decided that Medicare rules for coverage of 
services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay 
for the surgical services rendered on April 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the requested Intracept procedure is 
medically necessary. The Plan denied your request. The Plan says the requested Intracept procedure is not 
medically necessary. 
 
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 Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not medically necessary. Our physician reviewer found the 
Intracept procedure is experimental for back pain. More research is needed. At this time, the procedure is not 
medically necessary. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating 
provider on April 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that the new dentist needed to evaluate your teeth. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 14, 2022.  
 
 
 
 
 Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a 
participating provider on April 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injection on April 12, 2022. 
 
You asked the Plan to waive the coinsurance for injection. You say that you were informed from the providers 
office that it was covered at 100%. You would like the claim to be reprocessed and paid and your responsibility 
to be $0. 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 20% 
coinsurance for Medicare Part B covered drugs at primary care physicians (PCP) office, specialists office or 
pharmacy. These drugs are covered under Part B of Original Medicare. Members of our plan receive coverage 
for these drugs through our plan. Covered drugs include drugs that usually aren't self-administered by the 
patient and are injected or infused while you are getting physician, hospital outpatient, or ambulatory surgical 
center services. The provider billed in the amount of $2,580 and the allowed amount is $1,377.60. $1,377.60 x 
20% = $275.52. Therefore, results in the total cost sharing amount of $275.52. 
 
 You have been asked to pay a 20% coinsurance for injection. Injections fall within the Medicare Part B 
prescription drugs 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 injection on April 
12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from May 
17, 2022, to May 20, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that the copayment should not 
apply. 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 $350 per 
day for days 1-5 and $0 per day for days 6-90 for each inpatient admission.  
 
The file shows that you were in the hospital from May 17, 2022, to May 20, 2022. Since there is no copayment 
for the discharge date, you have been asked to pay $350 per day for days 1-3 of inpatient care. The total for 
your stay is $1,050 ($350 copayment x 3 days = $1,050). The inpatient care 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 copayment for inpatient hospital care provided 
from May 17, 2022, to May 20, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a phenylephrine ketorolac irrigation 
solution provided on May 17, 2022. 
 
You asked the Plan to waive the coinsurance for the phenylephrine ketorolac solution. You say that you were 
under the impression that the procedure would only cost $200. The Plan denied your request. The Plan says the 
correct coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for each Part B drug.  
 
You have been asked to pay $82.26, which is 20% of the allowed amount for the phenylephrine ketorolac 
solution ($411.28 allowed amount x 20% coinsurance = $82.26). The phenylephrine ketorolac solution falls 
within the Medicare Part B Prescription Drugs 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 a phenylephrine ketorolac irrigation solution provided on May 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an emergency room (ER) visit and 
inpatient hospital care provided from September 11, 2020, to September 15, 2020. We also decided that the 
Plan does not have to waive the copayment for hospital observation care provided from May 3, 2021, to May 5, 
2021. 
 You asked the Plan to waive the copayments for the ER visit, inpatient care, and observation care. You say that 
the cost sharing amounts are too high. 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 $90 
copayment for each emergency room visit. 
 
Your contract with the Plan also clearly says that you must pay $250 per day for days 1-6, up to a maximum of 
$1,500, for each inpatient admission. 
 
Your contract with the Plan also clearly says that you must pay a $375 copayment for each observation stay. 
 
You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the Emergency Care 
benefit category. You have also been asked to pay $250 per day for days 1-4 of inpatient care, for a total of 
$1,000 ($250 copayment x 4 days = $1,000). The inpatient care falls within the Inpatient Hospital Care benefit 
category. You have also been asked to pay a $375 copayment for the observation care. The observation care 
falls within the Outpatient Hospital Observation benefit category. The total for all services is $1,465. 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 (ER) visit and inpatient hospital care 
provided from September 11, 2020, to September 15, 2020. We also decided that the Plan does not have to 
waive the copayment for hospital observation care provided from May 3, 2021, to May 5, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says physical therapy services are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 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 
skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition. 
Our physician reviewer found that in this case, you have previously been treated with outpatient therapies and 
you or your caregivers should be independent with a home exercise program and the ongoing treatment of your 
lower extremities. There is no documentation of a recent injury or decline in function. The additional therapy 
services are not an appropriate duration and frequency for treatment of your medical condition and therefore 
are not medically necessary.  
 
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 physical therapy services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for he FoundationOne CDx (F1CDx) test (0037U) provided 
March 1, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the provision of F1CDx to the enrollee meets 
the requirements of the NCD and has been determined by CMS to be reasonable and necessary for the 
management of the enrollee's advanced cancer. The Plan denied your request. The Plan says does not meet 
Medicare NCD/LCD criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of he FoundationOne CDx (F1CDx) test 
(0037U) provided March 1, 2022. have been met. Records was required to determine how the enrollee came to 
the servicing provider or whether the services are medically necessary. The Plan made multiple attempts to 
obtain the needed information from the provider without success.. Therefore, we decided that the Plan does not 
have to pay for he FoundationOne CDx (F1CDx) test (0037U) provided March 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the member does not have clinical conditions that cannot be 
appropriately treated in the current hospital. 
 
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. The patient 
appears to be stable and improving and should only require short-term additional acute care services that can be 
safely administered at the current facility until more appropriate for a lower level of care. The patient does not 
require services at the LTACH that are not already available at the current facility. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous injection of allogeneic cellular and/or 
tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar. 
 
You asked the Plan to pre-approve a percutaneous injection of allogeneic cellular and/or tissue-based product, 
intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar. The Plan denied your 
request. The Plan says a Percutaneous injection of allogeneic cellular and/or tissue-based product, 
intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar is not medically 
necessary. 
 
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 a percutaneous injection of allogeneic 
cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar. Our reviewer says that a percutaneous injection of allogeneic cellular and/or tissue-based 
product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar is not 
considered medically reasonable and necessary. Our physician reviewer found this is an experimental/ 
investigational procedure. Therefore, the request is deemed not medically reasonable or necessary. 
 
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 percutaneous injection of allogeneic cellular and/or tissue-based product, 
intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a percutaneous injection of allogeneic cellular 
and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, 
lumbar.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit with a specialist provided on 
June 1, 2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that you are appealing this cost-
sharing. 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 $25 
copayment for an office visit with a specialist.  
 
You have been asked to pay a $25 copayment for an office visit with a specialist. The office visit falls within 
the Physician/Practitioner Services, Including Doctors 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 the office visit with a specialist provided on June 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral hygiene instructions (D1330) provided on April 14, 
2022. 
 
You asked the Plan to pay for hygiene instructions. You say that you get two free cleanings a year. The Plan 
denied your request. The Plan says oral hygiene instructions (D1330) are not covered by your routine dental 
benefits. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for oral 
hygiene instructions (D1330) provided on April 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for vision services provided on  
February 3, 2022. 
 
You asked the Plan to pay an additional amount for vision services. The Plan denied your request. The Plan 
says the Plan has paid the $300 vision allowance to the provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 
We looked at the file and the Plan's rules. The file shows that the Plan has paid the maximum allowance for the 
vision care services. Therefore, we decided that the Plan does not have to pay an additional amount for vision 
services provided on February 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paravertebral facet joint injections (64493-50 x2 and 
64494-50) provided on February 15, 2022. 
 
You asked the Plan to pay for codes 64493-50 x2 and 64494-50. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64493 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. We have also confirmed that code 64494 is an add-on code and as the primary code 
is not payable, the add-on code is not payable as well. Based on this information, we decided that Medicare 
rules for coverage of codes 64493-50 x2 and 64494-50 have not been met. Therefore, we decided that the Plan 
does not have to pay for the paravertebral facet joint injections (64493-50 x2 and 64494-50) provided on 
February 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service August 30, 
2021. 
 
You asked the Plan to pay for procedure code 99100. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 99100 is considered bundled 
and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service August 30, 2021.