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

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service November 
14, 2022. 
 
You asked the Plan to pay for procedure code 71045. You say that the member had multiple exams done on 
this date of service. The Plan denied your request. The Plan says payment for code 71045 is bundled into 
payment for code 71046. 
 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 71045 
is a column II code to column I code 71046. 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 71045 billed for date of service November 14, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the medical services provided from April 
19, 2022, to November 29, 2022. 
 
You asked the Plan to waive the coinsurance for the medical services. You say that you do not agree with the 
coinsurance. You say that you pay the applicable copayments when required. You also say that you were not 
aware you were responsible for additional charges other than copayments. 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 5% 
coinsurance for services received in-network.  
 
You have been asked to pay a 5% coinsurance for the medical services at issue in this case. These 
items/services fall within the Medicare Part B prescription drugs, and Outpatient diagnostic tests and 
therapeutic services and supplies 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 coinsurance for 
the medical services provided from April 19, 2022, to November 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the refraction provided on November 3, 2022. 
 
You asked the Plan to pre-approve the refraction. You say that you do not agree with the $30 charge for the 
refractions. You say you were not aware your benefits changed. The Plan denied your request. The Plan says 
the service is not a covered benefit. 
 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 provided as a part of a routine eye exam. 
 
We looked at the file and the Plan's rules. Specifically, the refraction was not performed with a routine eye 
exam. The medical record shows diagnoses of cataracts and eyelid inflammation which makes the eye exam 
medical in medical. Based on this information, we decided that the Plan's rules for coverage of the refraction 
have not been met. Therefore, we decided that the Plan does not have to pre-approve the refraction provided on 
November 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve white glass with metal crown (D2751) Tooth #6 and 
partial upper denture (D5213). 
 
You asked the Plan to pre-approve the dental services. You say that services were denied because you 
supposedly received a crown within the last 5 years; however, that is not true. 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. This benefit includes the 
requested D2751 and D5213, but each are limited to once per 60 months. 
 
We looked at the file, the Plans rules, and Medicares rules. You previously received covered white glass with 
metal crown (D2751) Tooth #6 on date of service October 19, 2018, and received covered  partial upper 
denture (D5213) on date of service May 12, 2022. Therefore, these benefits were exhausted on October 19, 
2018, and May 12, 2022. Therefore, we decided that the Plan does not have to pre-approve white glass with 
metal crown (D2751) Tooth #6 and partial upper denture (D5213).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital or observation care (99223) provided on July 
31, 2022. 
 
You asked the Plan to pay for initial hospital or observation care (99223). You say that the enrollee's treatment 
was determined to be medically appropriate and necessary by the treating physician. You say that there is 
sufficient documentation in the record that supports medical decision making of high complexity, a 
comprehensive history and comprehensive examination associated with the service provided. The Plan denied 
your request. The Plan says procedure code 99223 is 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 code 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 
  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 initial hospital or observation care (99223). Our reviewer 
says that the documentation does not support procedure code 99223. Our reviewer found the evaluation and 
management code billed requires a comprehensive history, a comprehensive examination and medical decision 
making of high complexity. However, the medical records submitted do not support a medical decision making 
of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of initial hospital or observation care (99223) have not been met. Therefore, we 
decided that the Plan does not have to pay for initial hospital or observation care (99223) provided on July 31, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the medical services provided on July 28, 2022, 
by an out-of-network (OON) provider, outside of the country. 
 
You asked the Plan to reimburse you for the medical services. You say that you had surgery outside of the 
country. You also say that you submitted all of the paperwork to get reimbursed. The Plan denied your request. 
The Plan says services received out-of-network are not covered. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Specifically, the record does not support that the services in this case were urgent or emergent. Therefore, we decided that the Plan does not have to reimburse you for 
the medical services provided on July 28, 2022, by an out-of-network (OON) provider, outside of the country.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the spine radiological examination (x-ray) (72040) and chest 
x-ray (71045), provided on October 13, 2022. 
 
You asked the Plan to pay for the portable x-ray services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says these are not covered services. 
 The Plan must follow Medicare rules. Medicare rules say that procedures and examinations which are not 
covered under the portable x-ray provision include the following: 
 Procedures involving fluoroscopy; 
 Procedures involving the use of contrast media; 
 Procedures requiring the administration of a substance to the patient or injection of a substance into the 
patient and/or special manipulation of the patient; 
 Procedures which require special medical skill or knowledge possessed by a doctor of medicine or doctor of 
osteopathy or which require that medical judgment be exercised; 
 Procedures requiring special technical competency and/or special equipment or materials; 
 Routine screening procedures; and 
 Procedures which are not of a diagnostic nature. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the portable x-ray services have not been met. Therefore, we decided that the Plan does not have to 
pay for the spine radiological examination (x-ray) (72040) and chest x-ray (71045), provided on October 13, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that the enrollee needs this. The Plan denied your request. 
The Plan says a CGM is not medically necessary for the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre 2 continuous 
glucose monitor (CGM).
Appeal type: Drugs
Decision: Partially Favorable

 
We decided that the Plan has to reduce the cost sharing for the injection. We decided that the Plan does not 
have to waive the cost sharing for the injection.  
 
You asked the Plan to waive the cost sharing for the denosumab injection provided by an in-network provider 
on October 3, 2022. You say that you do not agree with the cost sharing applied to this service. The Plan says 
that this cost sharing was charged correctly. 
 
 We decided that the Plan has to reduce the cost sharing for the injection.  
 
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 says that you must pay a 20% 
coinsurance for each in and out-of-network Medicare-covered Part B drug received in a providers office or 
outpatient setting. 
 
The Plan says you must pay a $270.12 coinsurance for Medicare Part B prescription drugs. Based on the Plan 
contract, however, you cannot be asked to pay more than a 20% coinsurance for Medicare Part B prescription 
drugs. In this case, 20% of the $1328.99 allowed amount is $265.80 ($1328.99 x .20 = $265.80 rounded up). 
Therefore, we decided that the Plan has to reduce the cost sharing for the injection.  
 
We also decided that the Plan does not have to waive the cost sharing for the injection. 
 
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 in and out-of-network Medicare-covered Part B drug received in a providers office or 
outpatient setting. 
 
The denosumab injection falls within the Medicare Part B prescription drugs benefit category. This means that 
you are responsible for a $265.80 coinsurance for the injection. 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 sharing for the injection. 
 
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 SNF care provided from September 2, 2022, to October 1, 
2022. 
 You asked the Plan to pay for SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says the enrollee no longer had 
skilled nursing facility needs. 
 
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 pay for 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 did not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did 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 pay for SNF care provided from September 2, 2022, to October 1, 2022.
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 you need IRF care. The Plan denied your request. 
The Plan says criteria for admission to the IRF setting have not been met. 
 
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 you continue to have a need for skilled therapy with ongoing safety concerns and 
a potential for functional improvement however, the documentation doesnt support that you would meet criteria for admission to an IRF. There is no indication that you would require skilled rehabilitation in an IRF, 
participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits 
weekly to regain or maintain your functional status. You can receive further services at a lower level of care. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on October 28, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you feel 
you should not be charged for the services received. The Plan denied your request. The Plan says these services 
are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 28, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on October 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide. 
 
You asked the Plan to pre-approve a stair glide. You say that you contacted customer service and they advised 
that you would be paying 20 percent of the bill, and insurance would pay 80 percent of the bill. The Plan 
denied your request. The Plan says this item is considered a convenience item, not primarily medical in nature, 
and is not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for Eastern wellness services provided on August 5, 2022. 
 
You asked the Plan to pay for Eastern wellness services. You say that this provider has helped you with issues 
that other providers have not been able to. The Plan denied your request. The Plan says that the Plan covered 
30 minutes of this visit and each wellness visit may not exceed 30 minutes in duration. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan claims that they covered 30 minutes duration of this visit and that any 
additional duration of this visit is not covered. However, the Plan has not provided records or reasonable 
attempts to obtain records for this visit to support the codes as billed on this claim or support that this visit was 
greater than 30 minutes in duration. Therefore, the Plan has not shown that its decision to deny payment for 
these services is correct or justified according to your contract with the Plan. Therefore, we decided that the 
Plan has to pay for Eastern wellness services provided on August 5, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and intraoral radiographic 
images (D0220) provided on November 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denied dental services. 
The Plan denied your request. The Plan says your annual dental benefit for the year 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. On January 
27, 2022, the Plan paid $102.97 for dental services. On April 22, 2022, the Plan paid $51.99 for dental services. 
On April 28, 2022, the Plan paid $87.15 for dental services. On May 16, 2022, the Plan paid $243 for dental 
services. On July 18, 2022, the Plan paid $12 for dental services. On August 1, 2022, the Plan paid $148 for 
dental services. On August 8, 2022, the Plan paid $354.89 for dental services. For the year of 2022 the Plan 
paid $1,000 ($102.97 paid + $51.99 paid + $87.15 paid + $243 paid + $12 paid + $148 paid + $354.89 paid) for 
dental services; therefore, your annual dental benefit for the year was exhausted on the date of service of 
August 8, 2022. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) 
and intraoral radiographic images (D0220) provided on November 7, 2022.
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 for post-op assessment 
and for occupational therapy to increase strength and endurance. The Plan denied your request. The Plan says 
based on Medicare guidelines, the requested IRF services do not meet the requirements for approval. 
 
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 enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement however, the documentation doesnt support that the 
enrollee would meet criteria for admission to an IRF. There is no indication that the enrollee would require 
skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a 
physician with at least 3 visits weekly to regain or maintain his functional status. The enrollee can receive 
further services at a lower level of care. 
 
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.