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

 
We decided that the Plan does not have to waive the coinsurance and the copayment for the injection and the 
specialist office visit provided on November 24, 2021. 
 
You asked the Plan to waive the coinsurance and the copayment for the injection and the specialist office visit. 
You say that the cost share was not as much before and would like it fixed. The Plan denied your request. The 
Plan says the proper cost share was applied for the services that were rendered. 
  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 all other drugs covered under Medicare Part B. The total amount allowed for the injection was 
$2,019.47 with a coinsurance of $403.89 ($2,019.47 total amount allowed x 20% coinsurance). 
 
Your contract with the Plan also clearly says that you must pay a $35 copayment for Physician specialist 
services (including surgery second opinion, telehealth, and urgently needed services). The charged copayment 
for the specialist office visit was $30 which is less than the copayment amount of $35. 
 
You have been asked to pay a $403.89 coinsurance for the injection and a $30 copayment for the specialist 
office visit. The injection falls within the Medicare Part B prescription drugs benefit category. The specialist 
office visit falls within the Physician/Practitioner services, including doctors 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 coinsurance and the copayment for the injection and the specialist office 
visit provided on November 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the office visit (99213), the trimming of 
skin lesions (11056), nail trimming (G0127), and the nail debridement (11720) provided on June 30, 2021 and 
October 5, 2021. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
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 $35 
copayment for each Medicare-covered and non-Medicare-covered podiatry visit.   
 
 You have been asked to pay $70 ($35 copayment x 2) for the Medicare-covered podiatry visits provided. 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 the office visit (99213), the trimming of skin lesions 
(11056), nail trimming (G0127), and the nail debridement (11720) provided on June 30, 2021 and October 5, 
2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department visit for the evaluation and 
management of a patient (CPT code 99282) provided on November 2, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. Our records indicate a NCCI 
Procedure to Procedure (PTP) edit exists between 99282 and 99284. This PTP edit has a modifier indicator of 
1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was 
not billed with this PTP code edit. Furthermore, both claims were billed by billing the same billing group and 
both physicians have specialty Emergency Medicine. Therefore, we decided that the Plan does not have to 
pay for emergency department visit for the evaluation and management of a patient (CPT code 99282) 
provided on November 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT) code(s): 82728, 83540, 83550, 
and 83970) provided on August 24, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. The documentation 
submitted by the laboratory failed to show that the laboratory tests reported were unrelated to treatment of 
ESRD. Therefore, in accordance with CMS, the laboratory tests are the responsibility of the dialysis center and 
are not separately reportable by the laboratory. Therefore, we decided that the Plan does not have to pay for the 
laboratory services (CPT) code(s): 82728, 83540, 83550, and 83970) provided on August 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Simponi Aria for the enrollee. 
 
You asked the Plan to pre-approve Simponi Aria. You say that this drug is medically reasonable and necessary. 
The Plan denied your request. The Plan says that the enrollee does not have any stated contraindications to the 
preferred products. 
 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 Simponi Aria. Our reviewer says that 
Simponi Aria is not medically reasonable and necessary for the enrollee. The provided records do not clearly 
show that the patient had tried and failed either Humira or Enbrel or had a contraindication to such to help 
support the use of Simponi Aria at this time. A trial of Humira or Enbrel would not likely be less effective or 
produce worse side effects than Simponi Aria as all of these agents have similar effectiveness and safety data 
for the patient's condition based on currently available studies. Our physician reviewer found that the enrollee's 
condition does not meet step therapy criteria for Simponi Aria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Simponi Aria have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Simponi Aria for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia (CPT code 99100) provided on December 10, 
2021. 
 
You asked the Plan to pay for the anesthesia. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT code 99100, has a status indicator of 'B' on the CMS Physician Relative Value and is always bundled into 
payment for other services not specified and no separate payment is made per Medicare. Based on this 
information, we decided that Medicare rules for coverage of the anesthesia have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia (CPT code 99100) provided on December 10, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a nasal endoscopy provided on October 6, 
2021. 
 
You asked the Plan to reduce the copayment for a nasal endoscopy. You say that the procedure was not 
performed in an operating room and that it should not be considered minor surgery. You also say that according 
to the hospitals billing department you should not have to pay more than 5%, and the amount you should owe 
is $54.50. 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 $250 
copayment for in-network outpatient surgery at an outpatient hospital.  
 The record shows this claim was approved, and you have a cost sharing amount. A nasal endoscopy is 
considered a surgical procedure. You have been asked to pay the allowed amount of $166.15, which is less than 
the $250 copayment for a nasal endoscopy. A nasal endoscopy falls within the Outpatient Surgery and Other 
Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 nasal endoscopy provided on October 6, 2021.  
 
Your complaint about the code being considered a minor surgery is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent transport services, provided on October 6, 
2021. 
 
You asked the Plan to pay for the non-emergent transport service. You say that the service should be covered. 
The Plan denied your request. The Plan says the member was enrolled in hospice. 
 
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 the non-emergent transport services, provided on October 6, 
2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided to the enrollee on May 10, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid for. The Plan 
denied your request. The Plan says that the submitted documentation supports observation care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the review has determined that the record showed that at the time of inpatient admission the 
admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. The plan of care included further testing, antibiotics, labs, and 
medications. Podiatry consulted and evaluated wound with no obvious infection identified. Wound care was 
ordered, and the patient discharged home on 5/12 in stable condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for inpatient hospital services provided to the enrollee on May 10, 2021.  
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services provided to the enrollee from May 28, 
2021, to June 1, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says that the information received does not support an acute inpatient stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the review indicates that the record showed that at the time of inpatient admission the admitting 
physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the inpatient hospital services provided to the enrollee from May 28, 2021, to June 1, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, evaluation and management of the critically ill 
or critically injured patient; each additional 30 minutes (CPT code 99292) provided on June 5, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The Plan states they will cover the procedure code 99292 received on June 06, 2021. CPT code 99292 (2 Units) 
is supported on appeal. The procedure code 99292 received on June 05, 2021, remain denied. The submitted 
medical records do not support the units billed. Therefore, the billed CPT code cannot be verified. Based on 
this information, we decided that Medicare rules for coverage of the service have not been met.  
 
 Therefore, we decided that the Plan does not have to pay for critical care, evaluation and management of the 
critically ill or critically injured patient; each additional 30 minutes (CPT code 99292) provided on June 5, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical pathology services provided to the enrollee on 
September 13, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 88305 TC (1 Unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for surgical pathology services provided to the enrollee on September 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Euflexxa injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request cannot be approved. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 injection. Our reviewer says that the 
requested injection is not medically reasonable or necessary. Our physician reviewer found the records do not 
show that the above coverage criteria apply to this enrollee. The review has determined that the documentation 
does not support that Euflexxa is medically reasonable and necessary for the patient. The documentation does 
not support that the Euflexxa is safe and effective for the patient. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Euflexxa injection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (CPT code 90791) 
provided on September 21, 2021, a Licensed Marriage and Family Therapist (LMFT). 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that this is supposed to be 90791 
and the modifier is supposed to be HN. The Plan denied your request. The Plan says this provider is not 
recognized by Medicare. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the psychiatric diagnostic evaluation have not been met. Only 
marriage and family therapists are not recognized by Medicare. Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (CPT code 90791) provided on September 21, 2021, a 
Licensed Marriage and Family Therapist (LMFT).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Targeted genomic sequence analysis provided on March 26, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Targeted genomic sequence analysis. You say that this is medically necessary. 
The Plan denied your request. The Plan says the non-network provider does not work with the 
members health plan, and the member's primary care physician did not refer for services. 
 
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 Targeted genomic sequence analysis provided on 
March 26, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a panoramic radiographic image (D0330), a cone 
beam computed tomography (CT) capture (D0365), teeth extractions (D7140), alveoloplasty in conjunction 
with extractions per quadrant (D7310), guided tissue regeneration (D4266), surgical placement of an implant 
body (D6010), alveoloplasty in conjunction with extractions, one to three teeth (D7311), therapeutic parental 
drugs (D9612), bone graft at time of implant placement (D6104), evaluation for moderate sedation (D9219), 
deep sedation/general anesthesia (D9222) and unspecified adjunctive procedure (D9999) provided on June 21, 
0221, to July 30, 2021, by an out-of-network (OON) provider. 
 You asked the Plan to reimburse you for dental services. You say that you were told by the surgeon that they 
did not accept Medicare and that you would have to seek reimbursement on your own. You say you should not 
be responsible for paying the billed amounts because your provider referred you to the oral surgeon. You also 
say that tooth extractions can be risky to your health and the procedures you had should be covered under your 
medical insurance. The Plan denied your request. The Plan says the services were provided by a non-
participating provider. You are responsible for any difference between the maximum allowable fee and the 
amount the provider bills you for the services. The Plan also says there are in-network providers available for 
these services. 
 
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 reimburse you 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 reimburse you for these 
items/services. Therefore, we decided that the Plan does not have to reimburse you for a panoramic 
radiographic image (D0330), a cone beam computed tomography (CT) capture (D0365), teeth extractions 
(D7140), alveoloplasty in conjunction with extractions per quadrant (D7310), guided tissue regeneration 
(D4266), surgical placement of an implant body (D6010), alveoloplasty in conjunction with extractions, one to 
three teeth (D7311), therapeutic parental drugs (D9612), bone graft at time of implant placement (D6104), 
evaluation for moderate sedation (D9219), deep sedation/general anesthesia (D9222) and unspecified 
adjunctive procedure (D9999) provided on June 21, 0221, to July 30, 2021, by an out-of-network (OON) 
provider.