Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out-of-network services provided to the enrollee on January 
28, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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 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 out-of-network services provided to the enrollee 
on January 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the abdomen and 
pelvis. 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
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 the MRI. Our reviewer says that the 
MRI is not medically necessary. Our physician reviewer found the enrollee's evaluation to date has been 
appropriate and comprehensive. The request for the MRI is not demonstrated by available records, nor 
supported by the expressed opinions of the enrollee's providers. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the abdomen and pelvis.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electroencephalogram (EEG) provided during a surgical 
procedure on March 17, 2021, billed with code 95955. 
 
You asked the Plan to pay for the EEG services as billed. You say that code 95955 is supported and should be 
paid. The Plan denied your request. The Plan says this code 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 95955 is Electroencephalogram (EEG) during 
nonintracranial surgery (eg, carotid surgery). 
 
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 EEG services as billed. Our reviewer says that the code billed is not supported by the medical records. Our reviewer found the technical report documents "EEG was 
symmetric throughout the procedure. No lateralizing events were observed during this case". CPT 95955 is an 
inappropriate code to report for real-time monitoring. CPT 95955 is reported for Special EEG Tests. There is a 
more appropriate code to report for real time monitoring. Any additional EEG monitoring during this procedure 
would be included in the correct code for EEG monitoring during non-intracranial surgery.  
 
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 EEG services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the electroencephalogram (EEG) provided during a surgical procedure on March 
17, 2021, billed with code 95955.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive medication services on October 27, 2020. 
 
You asked the Plan to pay for the comprehensive medication services. You say that the member is being treated 
for several things and needs to continue care with his current specialist. The Plan denied your request. The Plan 
says the code is 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 H2010 is comprehensive medication services, per 15 
minutes. 
 
We find that CPT code H2010 is not supported in the medical record. Specifically, CPT code H2010 has a 
status indicator of I. This means that CPT code H2010 is not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of the comprehensive medication services have not 
been met. Therefore, we decided that the Plan does not have to pay for the comprehensive medication services 
on October 27, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) services 
rendered on February 25, 2021. 
 
You asked the Plan to waive the copayment for these services. You say that your provider advised you should 
be seen in the ER. The Plan denied your request. The Plan says the copayment was applied 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 $90 
copayment for each emergency room visit.  
 
Review of the file shows that you received ER services on February 25, 2021. You have been asked to pay a 
$90 copayment for these services. These services fall within the emergency room visit 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 emergency room (ER) services rendered on 
February 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crutch substitute or knee scooter (E0118).  
You asked the Plan to pre-approve a crutch substitute or knee scooter. You say that the item is necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that canes (E0100, E0105) and crutches (E0110, E0111, 
E0112, E0113, E0114, E0116) are covered if specific criteria are met. 
 
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 a crutch substitute or knee scooter. Our 
reviewer says that the item is not medically necessary. Our physician reviewer found a crutch substitute 
(E0118) or "knee scooter" is not medically necessary as there is no objective upper extremity physical 
examination indicating why the enrollee is unable to use crutches. There is no evidence that the requested 
device will be safe and effective for the enrollee to use in the home. The criteria per Social Security Act, 
Section 1862 (a)1(A) and the 42 CFR 411.15(k), for the requested E0118 have not been met and the E0118 is 
not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of 
a malformed body member. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a crutch substitute or knee scooter have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a crutch substitute or knee scooter (E0118).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 30, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that the enrollee showed his insurance card but was not 
informed during the visit that this doctor is out-of-network. The Plan denied your request. The Plan says the 
denial of payment for this service is correct, because this provider is out-of-network with the Plan and 
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 provided on March 30, 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 the specialist services rendered on August 
10, 2021. 
 
You asked the Plan to waive the copayment for these services. You say that telehealth services should have no 
copayment. The Plan denied your request. The Plan says the copayment was applied 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 $32 
copayment for each Medicare-covered Telehealth Specialist visit.  
 
Review of the file shows that you received telehealth specialist services on August 10, 2021. You have been 
asked to pay a $32 copayment for these services. These services fall within the Medicare-covered Telehealth 
Specialist visit 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 specialist services 
rendered on August 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage. 
 
You asked the Plan to pre-approve additional routine transportation mileage. You say that the additional 
transportation mileage is necessary. The Plan denied your request. The Plan says the benefit has been 
exhausted. Therefore, coverage criteria have not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers 24 one-way transportation trips when each one-way trip does not exceed 50 miles.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation mileage.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) stay 
provided May 1, 2021 to May 12, 2021. 
 
You asked the Plan to waive the copayment for the SNF stay. You say that you do not feel that this bill is 
correct. You should have been discharged sooner and you did not receive the care that you needed while in 
their care due to not being able to see a foot doctor while you were there. The Plan denied your request. The 
Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage. 
 
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 $0 
copayment for each day for days 1-20 and $184 copayment each day for days 21-57 for skilled nursing facility 
(SNF) care.   
You have been asked to pay $2,024.00 ($184 x 11 days) for the SNF stay. The SNF stay falls within the skilled 
nursing facility (SNF) 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 the skilled 
nursing facility (SNF) stay provided May 1, 2021 to May 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an esophagoscopy (43226) provided on April 28, 2021. 
 
You asked the Plan to pay for an esophagoscopy. You say that this is supported in the records. The Plan denied 
your request. The Plan says this is included in the global surgical package for the enrollee's thoracic duct 
procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for procedures 
with the appropriate entry in Field 16 of the Medicare Fee Schedule Data Base (MFSDB) includes payment for 
follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery. 
 
We looked at the file and Medicare rules. The records indicate that the service at issue was performed as a follow up in the post-operative period of the thoracic duct procedure performed on February 9, 2021. Based on 
this information, we decided that Medicare rules for coverage of an esophagoscopy have not been met. 
Therefore, we decided that the Plan does not have to pay for an esophagoscopy (43226) provided on April 28, 
2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care supervision (99379) provided on 
March 21, 2021. 
 
You asked the Plan to pay for the nursing facility care supervision. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says CPT code 99379 has a status 
indicator of B and payment is always bundled into another service or procedure. 
 
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 99379 is supervision of a nursing facility patient (patient 
not present) requiring complex and multidisciplinary care modalities involving regular development and/or 
revision of care plans by that individual, review of subsequent reports of patient status, review of related 
laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) 
and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment 
plan and/or adjustment of medical therapy, within a calendar month; 15-29 minutes. 
 
We find that CPT code 99379 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code 99379 has a status indicator of B. This means that the payment for CPT code 99379 is always bundled 
into the payment for another service or procedure. Based on this information, we decided that Medicare rules 
for coverage of the nursing facility care supervision have not been met. Therefore, we decided that the Plan 
does not have to pay for the nursing facility care supervision (99379) provided on March 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered an experimental/investigational procedure. Therefore, the request is 
deemed not medically reasonable or necessary. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first 
intraoral periapical x-ray (D0220), and simple extraction (D7140) provided on June 15, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and 
simple extraction. You say that you would like this claim to be covered under your medical insurance. The Plan 
denied your request. The Plan says these services are not covered expenses under your dental plan. 
 
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 pay for the 
problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), and simple extraction 
(D7140) provided on June 15, 2021.  
 
Please Note: The Plan forwarded this appeal information to the medical team to see if it can be covered under 
your medical plan. Please contact the Plan for more information.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specialist services provided on January 28, 2020 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for specialist services. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider 
is out-of-network with the Plan and 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 specialist services provided on January 28, 2020 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on December 17, 
2020. 
 
You asked the Plan to pay for a lumbar-sacral orthosis. You say that the item at issue is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says medical necessity rules for the item at issue have not 
been met. 
 
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 pay for a lumbar-sacral orthosis. Our reviewer says 
that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that an appropriate history and a physical examination of the back would reasonably be 
required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The 
documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered 
indications in this case, as there is insufficient documentation of an appropriate evaluation of the enrollee and 
insufficient documentation of a credible physical examination of the back. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan 
does not have to pay for a lumbar-sacral orthosis (L0650) provided on December 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for wound debridement services you received at an outpatient hospital facility from July 14, 2021, to August 16, 2021.
You asked the Plan to reduce the copayments for the wound debridement services. You say that you should only have to pay the specialist copayment of $30 for each date of service. The Plan denied your request. The Plan says you were charged these copayments 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 $150 copayment for outpatient hospital surgery services. You have been asked to pay a $150 copayment for the wound debridement services. Medicare considers wound debridement to be a surgical service. In addition, you received these services in a facility that is considered an
outpatient hospital facility. That is why the wound debridement services fall within the outpatient hospital surgery 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 reduce the copayments for wound debridement services you received at an outpatient hospital facility from July 14, 2021, to August 16, 2021.