Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 provided on February 28, 2022. 
 
You asked the Plan to pay for procedure code 99291. 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 99291 is Critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, code 99291 is a time-based 
code. In order to bill CPT code 99291, the documentation must note that the first 30-74 minutes was spent 
providing services to the enrollee. The progress note for February 28, 2022, 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 99291. Based on this information, we decided that Medicare rules for coverage of procedure code 99291 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99291 
provided on February 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the ultrasound provided on November 29, 
2022. 
 
You asked the Plan to reduce the copayment for the ultrasound. You say that you should only be charged for a 
specialist office visit. 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 $60 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $60 copayment for the ultrasound. 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 reduce the 
copayment for the ultrasound provided on November 29, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
November 15, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you do not think you 
should have to pay for this visit. 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 in and out-of-network Medicare-covered emergency room visits. 
 
You have been asked to pay a $50 copayment for an emergency room visit. This item/service falls within the in 
and out-of-network Medicare-covered emergency room 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 an emergency room visit provided on November 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 22845 billed for date of service September 
27, 2022. 
 
You asked the Plan to pay for procedure code 22845. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 22845 is bundled into payment for code 22853. 
 
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 22845 
is a column II code to column I code 22853. 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 22845 billed for date of service September 27, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-ray provided on January 03, 2023. 
 
You asked the Plan to waive the copayment for x-ray. 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 x-rays. 
 
You have been asked to pay a $50 copayment for x-ray. This item/service falls within the x-rays 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. You have been asked to pay $32.78 which is less than the standard $50 copayment for an x-ray. Therefore, we decided that the 
Plan does not have to waive the copayment for x-ray provided on January 03, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
You asked the Plan to pre-approve Feraheme. You say that the requested Feraheme is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Ferrlecit, Infed, or Venofer first. 
 
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 Feraheme. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of 
Ferrlecit, Infed, or Venofer first before they will approve the requested drug. In this case, the enrollee has not 
tried and failed the required drug(s). There is no documentation indicating that the Plans required drug(s) 
would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additional 11 an additional 11 physical therapy (PT) 
visits in addition to the 25 visits the plan already approved. 
 
 
 You asked the Plan to pre-approve the additional 11 PT visits. You say that the services are medically 
necessary.  The Plan denied your request. The Plan says the medical information received is not enough 
information for them to decide the medical need for additional physical therapy visits. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve PT visits. Our reviewer says that skilled 
services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. 
Our physician reviewer found the plan approved 25 visits and denied the additional 11 visits. 25 visits are 
reasonable following a knee replacement. A significant amount of rehabilitation following a knee replacement 
can be done with self-directed care at home. There are no indication the additional 11 visits are necessary at 
this time. There are no records available indicating based on the enrollee's response to therapy that the 
additional 11 visits are needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PT visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the additional 11 an additional 11 physical therapy (PT) visits in addition to the 25 visits the 
plan already approved.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the sleep study provided on December 21, 
2022. 
 
You asked the Plan to waive the copayment for the sleep study. You say that you are not satisfied with the 
services rendered. 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 outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $50 copayment for the sleep study. 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 sleep study provided on December 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a CTA provided on September 2, 2022. 
 
You asked the Plan to reduce the copayment for a CTA. You say that previous claims for the same service were 
assessed with a lesser cost share. 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 $350 
copayment for outpatient diagnostic tests.  
 
 
  You have been asked to pay $337.19, which is less than the standard $350 copayment for a CTA. This 
item/service falls within the outpatient diagnostic tests 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 copayment for a CTA provided on September 2, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for physical therapy services provided on September 15, 2022. 
 
You asked the Plan to pay for physical therapy services. You say that the provider is a physical therapist and 
not a chiropractor. The Plan denied your request. The Plan says the physical therapy services were denied 
because they were provided by a chiropractor. 
 
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 says the physical therapy services were denied because they were 
provided by a chiropractor. The records clearly show the physical therapy services were provided by a physical 
therapist. This means that the Plan has not provided a valid reason for denying payment of the physical therapy 
services. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the denial 
has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for 
physical therapy services provided on September 15, 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) of the pelvis received on 
August 26, 2022. 
 You asked the Plan to pay for the CT of the pelvis. You say that this claim has been corrected and asked the 
plan to please reprocess the claim for payment. The Plan denied your request. The Plan says Original Medicare 
is responsible for the payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on August 2, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for a computed 
tomography (CT) of the pelvis received on August 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a walking boot provided on December 15, 
2022. 
 
You asked the Plan to waive the coinsurance for a walking boot. You say that you do not agree with paying for 
this item. 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 20% 
coinsurance for in-network prosthetic devices, supplies related to prosthetic devices, and orthotics. 
 
You have been asked to pay 20% coinsurance for a walking boot. This item/service falls within the in-network 
prosthetic devices, supplies related to prosthetic devices, and orthotics 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. The total you owe is $58.39 ($291.97 
allowed amount x 20% = $58.39) Therefore, we decided that the Plan does not have to waive the coinsurance 
for a walking boot provided on December 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation, cleaning, filling, pontic, 
crown (D0150, D1110, D2330, D2740, D6740, D6245) provided on December 23, 2022, to January 19, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental 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. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a comprehensive oral evaluation, cleaning, filling, pontic, crown (D0150, D1110, D2330, D2740, 
D6740, D6245) provided on December 23, 2022, to January 19, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit, and an electrocardiogram 
provided on October 29, 2022.  
You asked the Plan to pay for an emergency department visit and an electrocardiogram. You say that the 
enrollee has chest pain. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for an emergency department visit, and an electrocardiogram 
provided on October 29, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 18 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy visits. You say that the enrollee would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says 18 additional 
physical therapy visits are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve physical therapy visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found that the enrollee has no acute change in their knee or low 
back pain. The enrollee is independent with mobility and performing daily activities. Therefore, the enrollee 
can manage their pain with a home exercise program and the services of a skilled therapist are not needed for 
oversight of routine strengthening exercises. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 18 additional physical therapy visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the cervical spine. 
 
You asked the Plan to pre-approve an MRI of the cervical spine. You say that you would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says an MRI of the 
cervical spine is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 an MRI of the cervical spine. Our 
reviewer says that the requested MRI of the cervical spine is not medically necessary. Our physician reviewer 
found that there is an x-ray report of plain films of the cervical spine dated October 13, 2022, which describes 
lack of visualization below C6 and consideration of an MRI. The x-rays of the cervical spine were done over 6 
months ago there has not been any follow up information given. The medical necessity of the requested MRI 
has not been established in the material provided.  
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the cervical spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an MRI of the cervical spine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic pontic for tooth number 12 (D6245) 
and porcelain/ceramic retainer crowns for teeth number 11, 13, 21 (D6740 x 3). 
 
You asked the Plan to pre-approve the dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested items 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 items has been exhausted.  Specifically, the Plans contract states that up to four units of a fixed denture are covered per year. The Plan 
previously approved coverage for four units of a fixed denture for teeth number 17, 18, 19, 20. Therefore, you 
have exhausted the allowable benefit for the dental items requested in this case at this time. Therefore, we 
decided that the Plan does not have to pre-approve a porcelain/ceramic pontic for tooth number 12 (D6245) and 
porcelain/ceramic retainer crowns for teeth number 11, 13, 21 (D6740 x 3).