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

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that this is medically necessary. The Plan 
denied your request. The Plan says the denial of authorization for this service is correct, because the clinical 
value and effectiveness of bone marrow aspirate have not been established in this setting. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate remains experimental for use as bone graft material in spine 
surgery. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services provided during a 
hospital observation stay provided on December 15, 2020. 
 
You asked the Plan to waive the copayment for the specialist services. You say that you do not understand the 
charges. 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 $35 
copayment for specialist services.  
 
The file shows that there was no charge for the observation care. The provider decided to bill as an office visit, 
resulting in a lower copayment. Therefore, you have been asked to pay a $35 copayment for the specialist 
services. The specialist services 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 specialist services provided 
during a hospital observation stay provided on December 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) provided by a participating provider on 
December 9, 2021. 
 
You asked the Plan to pay for prophylaxis. You say that you have diabetes, and you need these cleanings. The 
Plan denied your request. The Plan says the benefit limit for D1110 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 Plan's coverage rules apply in this case. The Plan covers prophylaxis 
twice per plan year.  
 
We looked at the file and Medicare rules. Evidence was provided to show that D1110 was previously provided 
twice in the plan year. Based on this information, we decided that the Plan's rules for coverage of prophylaxis 
have already been met. Therefore, we decided that the Plan does not have to pay for prophylaxis (D1110) 
provided by a participating provider on December 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
October 26, 2021, to October 31, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you should not have to pay 
again when this stay began less than 24 hours after the last one. 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 after day 5 for each inpatient stay.  
 
The file shows that you were in the hospital from October 26, 2021, to October 31, 2021. Since this admission 
is a new stay at a different location, you have been asked to pay $350 per day for the first 5 days of inpatient care. The total for your stay is $1,750 ($350 copayment x 5 days = $1,750). 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 October 26, 2021, to October 31, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right and left cataract eye surgery to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve right and left cataract eye surgery to be provided by an OON provider. You 
say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers 
that are able to provide these services. Therefore, coverage criteria have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 
right and left cataract eye surgery to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
abdomen and pelvis provided on January 7, 2022. 
 
You asked the Plan to waive the copayment for the CT scan. You say that the scan was ordered by your doctor 
and was approved by the Plan. 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 $325 
copayment for each CT scan.  
 
You have been asked to pay $228.38, which is less than the $325 copayment for the CT scan. The CT scan 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 a computed tomography (CT) scan of the abdomen and pelvis 
provided on January 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Hospital discharge day management services (99239) 
provided on August 3, 2021. 
 
You asked the Plan to pay for code 99239. 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. 
 
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 99239 is Hospital discharge day management; more than 
30 minutes.  
We find that CPT code 99239 is not supported in the medical record. Specifically, code 99239 is a time-based 
code. To bill CPT 99239, the documentation must note that more than thirty minutes was spent providing 
services to the enrollee on the day of discharge. The progress note for August 3, 2021 does not note how much 
time was spent providing services to the enrollee. As such, the provided documentation does not support the 
billing of code 99239. Based on this information, we decided that Medicare rules for coverage of code 99239 
have not been met. Therefore, we decided that the Plan does not have to pay for the Hospital discharge day 
management services (99239) provided on August 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a vascular duplex study and vascular 
surgery office visit provided on January 11, 2022. 
You asked the Plan to waive the copayments for duplex scan and specialist visit. You say that you are 
appealing these amounts. The Plan denied your request. The Plan says the copayment amounts you are being 
charged are 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 $50 
copayment for vascular study and $5 copayment for specialist visit. Your total copayment amount is therefore 
$55. 
 
You have been asked to pay $50 copayment for vascular study and $5 copayment for specialist visit. Duplex 
scan and specialist visit fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" 
and "Physician/Practitioner Services, Including Doctor's Office Visits" benefit categories. 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 a vascular duplex study and vascular surgery office visit provided 
on January 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of an established patient (99336) rendered by the out-of-network (OON) provider on August 20, 
2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established 
patient (99336) rendered by the out-of-network (OON) provider on August 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments and coinsurance for vedolizumab injections 
and administration provided from November 19, 2021, to January 3, 2022. 
 
You asked the Plan to waive the copayments and coinsurance for the injections and administration. You say 
that you were not informed that the charges would be over $1,000. The Plan denied your request. The Plan says 
the correct copayments and coinsurance were 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 chemotherapy drugs. 
 
Your contract with the Plan also clearly says that you must pay a $40 copayment (2021) and a $50 copayment 
(2022) for specialist services. 
 
Service/Drug Allowed Amount Copayment/20% Coinsurance 
Chemotherapy Administration  November 19, 2021 - $40 (Copayment) 
Chemotherapy Administration  December 3, 2021 - $40 (Copayment) 
Chemotherapy Administration  January 3, 2022 - $50 (Copayment) 
Vedolizumab  November 19, 2021 $4,807.13 $961.43 (Coinsurance) 
Vedolizumab  December 3, 2021 $4,807.13 $961.43 (Coinsurance) 
Vedolizumab  January 3, 2022 $4,807.13 $961.43 (Coinsurance) 
Total:  3,014.29 
 
You have been asked to pay $2,884.29 for the chemotherapy injections, which is 20% of the allowed amount. 
The injections fall within the Medicare Part B Prescription Drugs benefit category. You have also been asked 
to pay $130 for the chemotherapy administration copayments. The chemotherapy administration falls within 
the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. The total for all visits is 
$3,014.29. 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 and coinsurance for vedolizumab injections 
and administration provided from November 19, 2021, to January 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Immunizations provided on October 18, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Immunizations. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services were not urgent or emergent. 
 
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 Immunizations provided on October 18, 2021 by 
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 debridement services (11042) provided on 
December 14, 2021, and December 21, 2021. 
 
You asked the Plan to waive the copayment for the debridement services. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0-250 
copayment for Outpatient hospital services.  
 
 
  You have been asked to pay a $500 copayment for two debridement services ($250 x 2 = $500). Debridement 
services fall 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 debridement services (11042) provided on December 14, 2021, and December 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit provided on December 15, 
2021. 
 
You asked the Plan to waive the deductible for an office visit. You say that you do not understand why you 
received the bill because the copayment for primary care is $5. The Plan denied your request. The Plan says the 
deductible applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $1500 deductible which applies which applies to out-of-network 
services.  
 
The item or service you asked the Plan to waive the deductible falls within the Physician/Practitioner services, 
including doctors office visits benefit category. The Plan has followed Medicare rules by clearly disclosing in 
the contract that the deductible applies to out-of-network services. This cost sharing is a contractual obligation 
that had not been met at the time for an office visit was received on December 15, 2021. Therefore, we decided 
that the Plan does not have to waive the deductible for an office visit provided on December 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98940) rendered by 
the out-of-network (OON) provider on August 24, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the chiropractic manipulative treatment (98940) rendered by the out-of-network 
(OON) provider on August 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the stress test and Part B prescription drugs 
provided on February 11, 2022. 
 
You asked the Plan to waive the cost share for the stress test and Part B prescription drugs. You say that you 
don't feel you should pay extra for the drug/injection codes. The Plan denied your request. The Plan says the 
cost share 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 a $425 
copayment for each Medicare-covered stress test and 20% coinsurance for each Medicare-covered Part B drug.  
 
You have been asked to a total cost share of $254.38 for the stress test and Part B prescription drugs. Please 
note, for the stress test the standard $425 copayment was reduced to the allowed amount of $206.62. 
 
Service Allowed Amount Standard Cost Member Liability 
Stress Test $206.62 $425 $206.62 
Part B Drugs $238.80 20% $47.76 
TOTAL:   $254.38 
 
Stress tests fall within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. 
The Part B drugs 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 cost share for the stress test and Part B prescription drugs provided on February 11, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair elevation (E2300), a power 
wheelchair accessory, attendant control (E2331), a tru-balance 3 fronted mounted cell phone holder, a 
wheelchair accessory, occupied transit option (K0108), a privacy flap and a Q-logic enhanced display kit 
(K0108). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the requested items are necessary due 
to the limited ability to control the enrollee's head. The Plan denied your request. The Plan says additional 
expenses for deluxe items that are for convenience or personal preference are not considered reasonable and 
necessary and are not covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of various wheelchair accessories have not been met. Specifically, the items 
requested are not covered by the Plan or Medicare. Therefore, we decided that the Plan does not have to pre-
approve a power wheelchair elevation (E2300), a power wheelchair accessory, attendant control (E2331), a tru-
balance 3 fronted mounted cell phone holder, a wheelchair accessory, occupied transit option (K0108), a 
privacy flap and a Q-logic enhanced display kit (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extractions (D7210 x11), a complete lower denture 
(D5120), and a complete upper denture (D5110). 
 
You asked the Plan to pre-approve extractions, a complete lower denture, and a complete upper denture. You 
say that the requested services are medically necessary. The Plan denied your request. The Plan says the 
services at issue are not covered 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 pre-approve 
extractions (D7210 x11), a complete lower denture (D5120), and a complete upper denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillary partial denture (D5225) provided by a contracted 
provider on September 28, 2021. 
 
You asked the Plan to pay for a maxillary partial denture. You say that you believe that this should be covered. 
The Plan denied your request. The Plan says the enrollee has not been enrolled with a dental rider; therefore, 
D5225 is not a covered dental benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for a maxillary partial denture 
(D5225) provided by a contracted provider on September 28, 2021.