Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-ray (D0270) provided on October 3, 2022, 
and the crown (D2740) provided on October 5, 2022. 
 
You asked the Plan to pay for the bitewing x-ray and crown. You say that your dental allowance is not enough 
and the x-ray was necessary. The Plan denied your request. The Plan says you have exceeded the frequency 
limit for the bitewing x-ray and you have exhausted your $1,000 dental allowance for 2022. 
 
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 bitewing 
x-ray once per plan year. The Plan covers supplemental dental benefits up to a $1,000 annual maximum.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a bitewing x-ray was 
previously covered on June 7, 2022. The documentation also shows that the Plan has covered the maximum 
$1,000 for dental services in 2022. Based on this information, we decided that you have exceeded your dental 
benefit for these services. Therefore, we decided that the Plan does not have to pay for the bitewing x-ray 
(D0270) provided on October 3, 2022, and the crown (D2740) provided on October 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by the requested out-of-
network provider. 
 
You asked the Plan to pre-approve an office visit to be provided by the requested out-of-network provider. You 
say that the enrollee does not have the ability to get to Utah for an evaluation. The Plan denied your request. 
The Plan says the Plans provider has board certified neuropsychologists and practitioners who specialize 
in neurocognitive and memory disorders. The Travel Benefit is established to offset the cost of travel for 
patients and their support person family members when Utilization Management provides and/or covered 
person, as an option for tertiary care (evaluation and or treatment), authorization to receive treatment from the 
Plan Center of Excellence facilities. The benefit allows a maximum of $200 per day for all covered living 
expenses, up to a cumulative limit of $2,000 per trip (includes covered living expenses for the patient and 
his/her primary caregiver; if the patient is a minor, covered living expenses for the patient and his/her parents 
or family members).  
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office 
visit to be provided by the requested out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravenous infusion, sotrovimab, includes infusion and post 
administration monitoring (code M0247), infusion, normal saline solution, 1,000 cc (code J7030) and injection, 
sotrovimab, 500 mg (code Q0247) provided on January 21, 2022. 
 
You asked the Plan to pay for intravenous infusion, sotrovimab, includes infusion and post administration 
monitoring, infusion, normal saline solution, 1,000 cc and injection, sotrovimab, 500 mg. The Plan denied your 
request. The Plan says the Plan requires utilization of network providers when possible and available and 
requires authorization for certain services. No medical necessity for an out-of-network provider such as an 
urgent or an emergent situation that has been documented.   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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for intravenous infusion, sotrovimab, includes infusion and post 
administration monitoring (code M0247), infusion, normal saline solution, 1,000 cc (code J7030) and injection, 
sotrovimab, 500 mg (code Q0247) provided on January 21, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for implantable, insertable, and wearable cardiac device evaluations  
(codes 93284, 93290) provided on January 6, 2022. 
 
You asked the Plan to pay for implantable, insertable, and wearable cardiac device evaluations. You say that 
the services are medically necessary. The Plan denied your request. The Plan says that this claim is a duplicate 
of a claim that has already been considered for payment and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. The Plan has not provided us with the original claim 
that was considered for payment. Based on this information, we decided that Medicare rules for coverage of 
implantable, insertable, and wearable cardiac device evaluations have been met. Therefore, we decided that the 
Plan has to pay for implantable, insertable, and wearable cardiac device evaluations (codes 93284, 93290) 
provided on January 6, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic comprehensive preventive medicine exam 
provided on September 7, 2022. 
 
You asked the Plan to pay for the periodic comprehensive preventive medicine exam. You say that you know 
that you are entitled to the physical and you were not advised that you needed to wait, especially if switching 
providers. You say that you assumed this exam would be covered as it was with a new provider. The Plan 
denied your request. The Plan says you have exhausted the annual physical exam benefit. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for a periodic comprehensive preventive medicine 
exam provided on September 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve resin-based composite - three surfaces, posterior  
(code D2393) for tooth #29 and #30. 
 
You asked the Plan to pre-approve the dental services. You say that the dental services are medically necessary. 
The Plan denied your request. The Plan says your benefit for the requested dental 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 service was exhausted on date of service February 7, 2022. Therefore, we 
decided that the Plan does not have to pre-approve resin-based composite - three surfaces, posterior  
(code D2393) for tooth #29 and #30.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF care. The Plan denied your 
request. The Plan says criteria for admission to the IRF setting have not been met. The enrollee's ongoing 
skilled therapy and nursing needs can be provided at a lower 
level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services to be provided by an OON 
provider. 
 
You asked the Plan to pre-approve home health services. You say that home health services are medically 
necessary. The Plan denied your request. The Plan says the requested services are not covered with an out-of-
network provider. 
 
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 
home health services to be provided by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tier exception for formoterol fumarate. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the drug is not eligible for a tier exception. 
 
The Plan must follow Medicare rules. Medicare rules say that Part B drugs are not eligible for a Part D tier 
exception. 
 
We looked at the file and Medicare rules. The requested drug is covered under Part B Medicare and is not 
eligible for a Part D tier exception. Therefore, we decided that the Plan does not have to pre-approve a tier 
exception for formoterol fumarate.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on March 21, 2022, 
which included code 99215. 
 
You asked the Plan to pay for the outpatient hospital services as billed. You say that this should be paid. The 
Plan denied your request. The Plan says the OPPS does not allow payment of a claim which includes a status 
indicator B code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Code 99215 has a status indicator of "B" on the Outpatient Prospective Payment System (OPPS). This means 
that the code is not recognized by OPPS when billed by a facility. This error causes the claim to be returned to 
provider, so the remaining codes are also not payable until a corrected claim is submitted. Based on this 
information, we decided that Medicare rules for coverage of the outpatient hospital services as billed have not 
been met. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services provided 
on March 21, 2022, which included code 99215.
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 June 8, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the denial. 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 June 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for cataract surgeries provided from July 21, 
2022, to August 4, 2022. 
 
You asked the Plan to waive the copayments for the cataract surgeries. You say that you were informed there 
would be no charge for these services. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $300 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
 
  You have been asked to pay a $300 copayment for each of the cataract surgeries, for a total of $600. This 
item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers 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 cataract 
surgeries provided from July 21, 2022, to August 4, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says a SNF admission is not 
medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the established patient evaluation and management (EM) services 
provided on August 25, 2022, billed with code 99213-25. 
 
You asked the Plan to pay for the billed EM services. You say that this EM service should be paid. The Plan 
denied your request. The Plan says that there were no new conditions diagnosed or treated and no new 
prescription were provided to consider this 
service 99213 as a significant and separate evaluation and management service to bill with modifier 25. 
 
The Plan must follow Medicare rules. Medicare rules say that visits on the same day as minor surgery are only 
separately payable if a significant, separate EM service was provided, and the code is billed with modifier -25.  
 
We looked at the file and Medicare rules. We find that the claim reports three diagnosis codes for the EM visit 
billed, and another for the treatment codes 17000 and 17003. This is corroborated by the progress note which 
shows that while actinic keratoses were treated with liquid nitrogen, the enrollee had several other conditions 
evaluated during this visit. Although it is true that no new conditions were diagnosed, this is not a condition for 
proper use of modifier -25. The provider reviewed existing conditions with the enrollee during this visit, which 
were distinct and separate from the condition treated with 17000 and 17003. Based on this information, we 
decided that Medicare rules for coverage of the billed EM services have been met. Therefore, we decided that 
the Plan has to pay for the established patient evaluation and management (EM) services provided on August 
25, 2022, billed with code 99213-25.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on 
September 22, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that this should be covered. The 
Plan denied your request. The Plan says this cost sharing was charged 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 $50 
copayment for Specialist office visits. 
 
You have been asked to pay a $50 copayment for specialist office visit. This item/service falls within the 
Specialist 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 specialist 
office visit provided on September 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for cataract surgeries provided from May 2, 
2022, to June 6, 2022. 
 
You asked the Plan to reduce the copayments for the cataract surgeries. You say that the procedures were 
performed in an ambulatory surgical center and the copayments should be $125. The Plan denied your request. 
The Plan says this cost sharing was charged 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 $175 
copayment for surgery, procedures, and services at an outpatient hospital facility.  
 
 
  The file shows that the procedures were performed in the outpatient surgical department of a hospital facility. 
Therefore, you have been asked to pay a $175 copayment for each of the cataract surgeries, for a total of $350. 
This item/service falls within the surgery, procedures, and services at an outpatient hospital facility 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 copayments for cataract surgeries provided from May 2, 
2022, to June 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for remote pacemaker monitoring provided 
August 1, 2022, to October 31, 2022. 
 
You asked the Plan to waive the copayments for remote pacemaker monitoring. You say that this has always 
been covered at 100%. The Plan denied your request. The Plan says this cost sharing was charged 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 $45 
copayment for a specialist visit.  
 
You have been asked to pay $38.46 copayment for remote pacemaker monitoring provided on August 1, 2022. 
This is less than the standard copayment amount. This item/service falls within the specialist visit benefit 
category. You have also been asked to pay $38.46 for remote pacemaker monitoring provided on October 31, 
2022. This is less than the standard copayment amount. This item/service falls within the specialist visit benefit 
category. The amount you owe is $76.92 ($38.46 + $38.46 = $76.92). 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 remote pacemaker monitoring provided 
August 1, 2022, to October 31, 2022.