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

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on October 
27, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that a doctor ordered a follow 
up visit, and you should not have a copay. 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 $10 
copayment for a specialist office visit.  
 
You have been asked to pay a $10 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a 
specialist office visit provided on October 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 14, 2022. 
 
You asked the Plan to pay for the lab services. You say that the patient's physician deemed these lab services to 
be medically necessary, so they should be covered. The Plan denied your request. The Plan says you billed with 
an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab 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 lab services provided on October 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH admission 
criteria, and you would like reconsideration based on the records submitted. The Plan denied your request. The 
Plan says the enrollee does not meet all the requirements for LTACH care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that all medically necessary care is being provided in the current acute care setting. 
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine (90750) and administration fee (90471), 
provided on April 5, 2021. 
 
You asked the Plan to pay for the shingles vaccine and administration. You say that the services should be 
covered. The Plan denied your request. The Plan says this is not a covered benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine 
and administration. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccine and administration. Therefore, we decided that the Plan does not have to pay for the shingles vaccine 
(90750) and administration fee (90471), provided on April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost sharing for a zoledronic acid injection and 
intravenous (IV) services provided on October 20, 2022. 
 
You asked the Plan to reduce the cost sharing for the injection and IV services. You say that you were told you 
would only have to pay $17.53 for these services. 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% 
insurance for in-network Medicare-approved Part B drugs. Your contract also says you must pay a $40 
copayment for in-network services provided by a specialist. 
 
You have been asked to pay $8.34, which is 20% coinsurance of the allowed amount for the injection ($41.70 allowed amount x 20% coinsurance = $8.34). This item/service falls within the Medicare Part B drugs benefit 
category.  
 
You have also been asked to pay a $40 copayment for the IV services. This item/service falls within the 
physician/practitioner services benefit category. You have been asked to pay a total of $48.34 ($8.34 
coinsurance + $40 copayment = $48.34). 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 cost sharing for a 
zoledronic acid injection and intravenous (IV) services provided on October 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical assist on the knee arthroscopy (29880), provided 
on August 23, 2022. 
 
You asked the Plan to pay for the surgical assist on the knee arthroscopy. You say that the service was 
medically necessary. The Plan denied your request. The Plan says the record does not show that the provider of 
the surgical assistant service is a physician, physician assistant, nurse practitioner, or clinical nurse specialist. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the surgical assist on the knee 
arthroscopy (29880), provided on August 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for August 24, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 3 identifies technical component only stand alone codes. 
 
We looked at the file and Medicare rules. Billed procedure code 99153 has a PC/TC indicator of 3 and no 
separate PC payment. Therefore, we decided that the Plan does not have to pay for procedure code 99153 billed 
for August 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910), topical application of 
fluoride varnish (D1206), and crown - porcelain/ceramic (D2740) provided on November 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that this provider shows as an in-network provider 
on the Plan's website. 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 Plan's 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 periodontal maintenance (D4910), topical application of fluoride varnish (D1206), and crown - porcelain/ceramic (D2740) provided on November 16, 
2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an addition to lower extremity, above knee or knee disarticulation, 
acrylic socket (L5631). 
 
You asked the Plan to pre-approve an addition to lower extremity socket. You say that the enrollee is in dire 
need of a prosthetic as he is now confined to his wheelchair, and he is not able to have the mobility and 
independence that he once had. It is also stated that the enrollee is missing his limb above the right knee and 
needs to have the prosthetic as this will provide maximum daily living functions. The Plan denied your request. 
The Plan says that your request is not a covered benefit because this addition is not considered reasonable and 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 addition to lower extremity. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee has a diagnosis of acquired absence of the right knee. The enrollee 
was noted to be working at a railyard and lumber mill as a timber cutter prior to the amputation. His goal is to 
return to all activities with the use of a right transfemoral prosthesis for ambulation without assistive device. 
The Plan has confirmed that an above knee preparatory prefabricated prosthesis (L5585) was never provided to 
the enrollee. The records do not show that an above knee initial prosthesis (L5505) or an above knee 
preparatory (L5560, L5570, L5580, L5590, L5595, L5600) prosthesis was provided, therefore the requested 
socket L5631 is medically necessary per LCD (L33787). 
 
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 addition to lower extremity have been met. Therefore, we decided that the 
Plan has to pre-approve an addition to lower extremity, above knee or knee disarticulation, acrylic socket 
(L5631).  
 
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 the tetanus, diphtheria and pertussis (TDAP) booster (90715) 
and the administration (90471). 
 
You asked the Plan to pay for the TDAP booster and administration. You say that the services were medically 
necessary. The Plan denied your request. The Plan says these services are not covered. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the TDAP booster 
and administration. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the TDAP booster 
and administration. Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria and 
pertussis (TDAP) booster (90715) and the administration (90471).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (procedure code 99285) 
rendered on September 16, 2022. 
 
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 CPT 99284 is more appropriate for these services. 
 
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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in order to bill CPT 99285, a 
comprehensive history, comprehensive examination and high-complexity medical decision making must be 
documented. The provider records contain little information regarding the present illness, which leads to a void 
as to what/why medical decisions were taken. There is no evidence that the presenting problems were of high 
severity and posed an immediate significant threat to life or physiologic function. As such, the billing of CPT 
99285 is not supported. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency department services (procedure code 99285) rendered on September 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of dental crowns (caps) on damaged teeth 
(41899). 
 
You asked the Plan to pre-approve placement of dental crowns (caps). You say that you say that your dental 
condition is medical and you need an extensive medical restoration. The Plan denied your request. The Plan 
says this service is not covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
placement of dental crowns (caps) on damaged teeth (41899).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services billed with code 81001 for February 4, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.

The test at issue in this appeal, billed with code 81001, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services billed with code 81001 for February 4, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Zilretta 32mg injection. 
 
You asked the Plan to pre-approve Zilretta 32mg injection. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says that the requested drug is not medically necessary. 
 
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 Zilretta 32mg injection. Our reviewer 
says that the documentation supports that the requested drug is medically reasonable and necessary. Our 
physician reviewer found you have a history of right knee pain secondary to osteoarthritis. You have been 
treated with medical therapy and received a Zilretta injection in the right knee on March 22, 2022. Zilretta 
(triamcinolone acetonide extended-release injectable suspension) is indicated as an intra-articular injection for 
the management of osteoarthritis pain of the knee. The product label, available at drugs@fda, states: Limitation 
of Use: The efficacy and safety of repeat administration of Zilretta have not been demonstrated." [see Dosage 
and Administration (2.1)].  Based on the Label, it does not preclude use of the drug more than one time. In 
addition, based on the regulation 50.4.1 - Approved Use of Drug, Drugs or biologicals approved for marketing 
by the Food and Drug Administration (FDA) are considered safe and effective for purposes of this requirement 
when used for indications specified on the labeling. Therefore, the documentation supports that Zilretta is 
medically reasonable and necessary and is safe and effective for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta 32mg injection have been met. Therefore, we decided that the Plan has 
to pre-approve Zilretta 32mg 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided in the United Mexican States 
on September 29, 2022. 
 
You asked the Plan to pay for ambulance services. You say that you were taken to the hospital by ambulance. 
The Plan denied your request. The Plan says proof of payment has not been submitted so the claim cannot be 
paid at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside of the 
United States and its territories are only covered under limited, specified circumstances. The Plan has a 
worldwide coverage supplement that goes beyond Medicares coverage. For that reason, the Plans rules apply. 
The Plan covers worldwide emergency care services; however, you are responsible for payment upfront and 
must request reimbursement from the Plan. 
 
We looked at the file and Medicare rules. This service does not fall within Medicares coverage for out-of-
country services. While this ambulance transportation may be covered by the Plans worldwide benefits, this 
claim does not meet the Plans criteria for coverage because you have not submitted proof of up front payment 
for the service. Based on this information, we decided that Medicare rules for coverage of ambulance services 
have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services provided 
in the United Mexican States on September 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with code 81335 provided on May 10, 
2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab 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 lab services billed with code 81335 provided on May 10, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additional miles for routine transportation beyond 
the Plan's 50-mile limit. 
 
You asked the Plan to pre-approve the additional miles for routine transportation. You say that this 
transportation is needed to get to a periodontist appointment. The Plan denied your request. The Plan says the 
requested trip exceeds the Plan's mileage limit. 
 
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 routine transportation when each one-way trip does not exceed 50 miles of driving 
distance.  
We looked at your request, the records in the case file, and the rules. We verified that the requested trip is 
greater than 50 miles of driving distance. Based on this information, we decided that the Plans rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve the additional miles for routine transportation beyond the Plan's 50-mile limit.