Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient behavioral health services provided to the enrollee 
from April 2, 2022, to April 15, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says there was no risk posed of imminent harm to self or others. Services did not need to be 
provided only in the acute inpatient setting. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that it 
was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he 
was not showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive 
behaviors while not showing any acute threats of safety. The patient reported feeling safe in the hospital setting 
worried about his safety out the community. It did not appear medically necessary and reasonable to have 
psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates 
in question. The health plans denial of continued inpatient psychiatric services appears appropriate. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient behavioral health services provided to the enrollee from April 2, 2022, to April 15, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and electroencephalogram (99204, 95816) 
provided on May 23, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and electroencephalogram. 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 an office visit and electroencephalogram (99204, 
95816) provided on May 23, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional units of insertion of centrally inserted central 
venous catheter and related services provided to the enrollee on January 13, 2022. 
 
You asked the Plan to pay for the additional units. You say that this was medically necessary. The Plan denied 
your request. The Plan says the records submitted do not indicate that two separate services were performed or 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
In this case, the CPT Code Manual definition of the denied code is: 
 
CPT 77001: 
 
Fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or 
removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast 
injections through access site or catheter with related venography radiologic supervision and interpretation, and 
radiographic documentation of final catheter position) (List separately in addition to code for primary 
procedure) 
 
CPT 99152: 
 
Moderate sedation services provided by the same physician or other qualified health care professional 
performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an 
independent trained observer to assist in the monitoring of the patient's level of consciousness and 
physiological status; initial 15 minutes of intraservice time, patient age 5 years or older 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the additional units. Our reviewer says that the services at 
issue in this case were not supported by the medical records. Our reviewer found that the documentation does 
not support duplicate billing of any of the codes in question. The documentation describes a single instance of 
tunneled central venous catheter placement with associated ultrasound guidance, fluoroscopic guidance, and 
sedation. The codes appear to be reasonable for a single instance. However, there is no evidence that any of 
these codes were repeated on the day of service 
 
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 additional units have not been met. Therefore, we decided that the Plan does 
not have to pay for additional units of insertion of centrally inserted central venous catheter and related services 
provided to the enrollee on January 13, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services (procedure codes 28112, 28825) provided to the 
enrollee on May 20, 2022. 
 
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 that the denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
the denied codes is: 
 
CPT 28112: 
 
Ostectomy, complete excision; other metatarsal head (second, third or fourth) 
 
CPT 28825: 
 
Amputation, toe; interphalangeal joint 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the enrollee being treated for 
gangrene, not elsewhere classified and peripheral vascular disease. He underwent an amputation of left 2nd toe 
5 x 3 cm; partial ostectomy left second toe metatarsal head; and amputation of left 3rd toe distal phalanx on 
5/20/22. The procedure notes cite metatarsophalangeal joint was reached, the toe was disarticulated in its 
entirety and passed the toe off as a specimen. Ronguers were used to piecemeal remove the distal metatarsal 
bone until we had good bone. The tissue/skin necrosis extended proximally, and the skin was sharply excised to 
a level of healthy bleeding. Final wound measurements were 5 x 3 x 2.5cm, deepest level of excision was 
metatarsal head. The distal phalanx of the 3rd toe was likewise gangrenous and a distal guillotine amputation 
was performed, first incising the skin, deepening to the joint, and disarticulating and removing the distal 
toe. Therefore, the records do support that CPT 28112: ostectomy, complete excision; other metatarsal head 
(second, third, or fourth) and CPT 28825: amputation, toe; interphalangeal joint were actually rendered in this 
case. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
surgical services (procedure codes 28112, 28825) provided to the enrollee on May 20, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 2, 2022, by 
an OON provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services were rendered in good 
faith and were medically necessary. You say the provider depends on the hospital staff to verify eligibility and 
to obtain the proper authorization from the patient's insurance. The Plan denied your request. The Plan says the 
out-of-network services were not authorized. 
 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 subsequent nursing facility care provided on May 
2, 2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (procedure code 00812) provided to the 
enrollee on January 28, 2022. 
 
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 there was a missing/invalid modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 00812 is "Anesthesia for lower intestinal endoscopic 
procedures, endoscope introduced distal to duodenum; screening colonoscopy." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, the provider did not 
bill as required by Medicare coding regulations. PT is an invalid modifier to use with CPT 00812. This 
modifier is reported only with CPT 00811 when a screening colonoscopy becomes a diagnostic colonoscopy. 
The review has determined that the records did not support the use of CPT 00812 in this case.  
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 anesthesia services (procedure code 00812) provided to the enrollee on January 28, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for emergency room services on June 09, 
2022, to June 19, 2022. 
 
You asked the Plan to waive the copayments for emergency room services. You say that you want to appeal the 
amount being charged. 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 $120 
copayment for each Medicare-covered emergency room visit. 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. There were 3 visits. 3 x $120 = $360. Therefore, results in the total cost sharing 
amount of $360.  
 
 
 
 
 You have been asked to pay a $120 copayment for each emergency room service. This item/service falls 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 copayments for emergency room 
services on June 09, 2022, to June 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on June 22, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that this refraction was part of your yearly eye exam. 
The Plan denied your request. The Plan says it was confirmed that the services received were not for a routine 
eye exam. 
 
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. The Plan covers these services when it is performed during a routine vision exam. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that you received a medical eye exam 
for multiple diagnoses, and not a routine eye exam. Based on this information, we decided that the Plan's rules 
for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay 
for the eye refraction (92015) provided on June 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of impacted ear wax provided on July 25, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the removal of impacted ear wax. You say that you would like to appeal the 
denied claim. The Plan denied your request. The Plan says the rendering provider is an OON provider, and the 
visit was for routine ear wax removal with no symptoms to indicate the care was urgently needed. 
 
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 the removal of impacted ear wax provided on July 
25, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5261) purchased on April 13, 2022, from 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you would like to be reimbursed for some of the 
cost for buying the hearing aids. The Plan denied your request. The Plan says this claim was processed 
correctly. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use the Plan's hearing aid vendor.  
 
We looked at the file and the Plan's rules. Specifically, these hearing aids were purchased from a hearing aid 
vendor that is not Plan approved. Based on this information, we decided that the Plan's rules for coverage of the 
hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids 
(V5261) purchased on April 13, 2022, from an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapies provided on May 6, 
2022, to June 13, 2022. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you are requesting 
reconsideration for services advising you agreed to pay $65 per visit but was charged additional amounts for 
physical therapy. 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 $65 
copayment for outpatient rehabilitation services. You previously received 5 physical therapies, resulting in 
copayment amount of $325 ($65 for 5 physical therapies = $325). 
 
You have been asked to pay $65 copayment for each physical therapy. This item/service falls within the 
outpatient rehabilitation 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 therapies provided on May 6, 2022, to June 13, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Botox. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no documentation provided 
indicating that the plans required drugs would likely be less effective and/or likely have adverse effects for the 
enrollee. Medical therapy has proven beneficial for the treatment of the enrollee's medical condition and should 
be initiated prior to the use of Botox. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids, the ear mold, and the dispensing fee 
provided by an out-of-network provider on May 17, 2022. 
 
You asked the Plan to pay for the hearing aids, the ear mold, and the dispensing fee. You say that the medical 
records support the billed procedural codes. The Plan denied your request. The Plan says the provider was out-
of-network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids when provided by an in-network provider.  
 
We looked at this the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids, the ear mold, and the dispensing fee have not been met. Specially, the provider is 
out-of-network. Therefore, we decided that the Plan does not have to pay for the hearing aids, the ear mold, and 
the dispensing fee provided by an out-of-network provider on May 17, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the reading of an electrocardiogram (ECG) 
provided on May 18, 2022. 
 
You asked the Plan to waive the copayment for the reading of an ECG. You say that the service rendered 
should fall under the claim of when you received the device. 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 $10 
copayment for in-network other outpatient diagnostic tests.  
 
  You have been asked to pay a $10 copayment for the reading of an ECG. This item/service 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 the reading of an electrocardiogram (ECG) provided on May 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on April 29, 2022. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the services were rendered to the 
member at an assisted living facility (ALF) and the ALF is responsible for obtaining prior authorization for all 
their patients, which should also cover for the medical treatments provided by this doctor as it was rendered in 
good faith. The Plan denied your request. The Plan says the services were not urgent or emergent and the 
services could have been rendered by a Plan participating 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 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 a domiciliary or rest home visit provided on April 29, 2022.