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

 
We decided that the Plan does not have to pre-approve an office visit to be provided by the requested 
out-of-network provider. 
 
You asked the Plan to pre-approve the office visit to be provided by the requested out-of-network provider. 
You say that the member has been seeing an epilepsy specialist for over 5 years and before seeing this 
specialist, she was having twenty to fifty seizures at times in a day. The Plan says that the Plan does not cover 
out-of-network services rendered with the exceptions of the following: 
 Emergency care or urgently needed services that you get from an out-of-network provider. This includes 
worldwide coverage if covered by your plan. 
 If you need medical care that Medicare requires our plan to cover and providers in our network cannot 
provide this care, you can get this care from an out-of-network provider. For these types of referrals, you must 
obtain authorization before seeking care. Your PCP can assist you with obtaining authorization. In this 
situation, we will cover these services as if you got the care from a network provider. If you do not have a prior 
authorization before you receive services from an out-of-network provider, you may have to pay for these 
services yourself. 
 Renal dialysis services when you are temporarily outside the service area, or when prior authorized. 
 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office 
visit to be provided by the requested out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 82310, 82540, 84442, and 86334 provided on 
December 8, 2021. 
 
You asked the Plan to pay for codes 82310, 82540, 84442, and 86334. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services billed are 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. 
 
We find that CPT codes 82310, 82540, 84442, and 86334 are not supported in the medical record. Specifically, 
while code 82310 is supported by the laboratory testing for calcium, the numbers of units (two) are not 
supported.  
 
The submitted medical records do not support that code 82540 was performed. The medical records did not include lab results for this test. 
 
The submitted medical records do not support that code 84442 was performed. The medical records did not 
include lab results for this test. 
 
The submitted medical records do not support that code 86334 was performed. The medical records did not 
include lab results for this test. 
 
Based on this information, we decided that Medicare rules for coverage of codes 82310, 82540, 84442, and 
86334 have not been met. Therefore, we decided that the Plan does not have to pay for codes 82310, 82540, 
84442, and 86334 provided on December 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for electrocardiographic (ECG) monitoring 
provided on October 06, 2022. 
 
You asked the Plan to waive the copayment for electrocardiographic (ECG) monitoring. You say that you think 
the cost sharing should be lower. 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 $125 
copayment for diagnostic procedures and tests, including ultrasounds, at all locations of service. 
 
You have been asked to pay a $125 copayment for electrocardiographic (ECG) monitoring. This item/service 
falls within the diagnostic procedures and tests, including ultrasounds, at all locations of service 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 electrocardiographic (ECG) monitoring 
provided on October 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (procedure code 99152) rendered 
on May 19, 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 the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of code 99152 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older." 
 
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 the review has determined that the documentation submitted did not indicate the presence of an independent trained observer to assist in the 
monitoring of the patient's level of consciousness and physiological status. Therefore, the billed service was not 
supported. The records do not support that CPT 99152 was rendered in this case. 
 
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 moderate sedation services (procedure code 99152) rendered on May 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from January 14, 2022, 
to February 2, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you are 
appealing the partial recoupment of the services. The Plan denied your request. The Plan says the Payment Integrity post-service post-pay clinical validation audit shows that the provider has reported inpatient hospital 
services with the incorrect DRG. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871. 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 the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that in this case, there was no clinical or laboratory evidence of sepsis. The review has determined that the 
documentation did not support diagnosis code A41.9. The records support DRG 177.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services rendered from January 14, 2022, to February 2, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy visit provided on October 13, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy visit. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 psychotherapy visit provided on October 13, 2022, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Boost shakes. 
 
You asked the Plan to pre-approve Boost shakes. You say that you need this product due to being extremely 
underweight and you cannot afford to buy them. You also say that you would like the chocolate flavor. The 
Plan denied your request. The Plan says Boost shakes are not covered under your plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve Boost shakes.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service July 16, 
2022. 
 
You asked the Plan to pay for procedure code 76700. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 76700 is bundled into payment for code 93976. 
 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 76700 
is a column II code to column I code 93976. 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 76700 billed for date of service July 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Yupelri. 
 
You asked the Plan to pay for Yupelri. You say that this is too expensive. The Plan denied your request. The 
Plan says tier exception reviews are not allowed under Part B, who is paying for this drug. 
 
The Plan must follow Medicare rules. Medicare rules say that each Part D plan sponsor that provides 
prescription drug benefits for Part D drugs and manages this benefit through the use of a tiered formulary must 
establish and maintain reasonable and complete exceptions procedures subject to CMS approval for this type 
of coverage determination.  
 
We looked at the file and Medicare rules. Specifically, Tier exceptions do not apply to Part B drugs. Based on 
this information, we decided that Medicare rules for coverage of Yupelri have not been met. Therefore, we 
decided that the Plan does not have to pay for Yupelri.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93306 billed for date of service August 9, 
2022. 
 
You asked the Plan to pay for procedure code 93306. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this code is included in the facility payment and is not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code 93306. This means there 
is both a professional and technical component for the CPT code. In this case, an appropriate modifier to 
indicate the professional component has not been billed with CPT code 93306. Based on this information, we 
decided that Medicare rules for coverage of procedure code 93306 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 93306 billed for date of service August 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram provided on 
September 21, 2022. 
 
You asked the Plan to waive the copayment for the electrocardiogram. 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 $25 copayment for other outpatient diagnostic tests non-radiological diagnostic services.  
 
You have been asked to pay less than the $25 copayment for the electrocardiogram. This service falls within 
the other outpatient diagnostic tests non-radiological diagnostic 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 an electrocardiogram provided on September 21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 12, 2022, to 
September 15, 2022. 
 You asked the Plan to pay for the home health services as billed. 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 as 
billed. 
 
The Plan follows Medicare rules. The rules state that home health services under a plan of care are paid based 
on a 30-day period of care. 
 
We looked at the file and Medicare rules. In this case, the file shows that the claim submitted includes a 34-day 
period of care. Therefore, we decided that the Plan does not have to pay for the home health services provided 
from August 12, 2022, to September 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on June 8, 2021. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says there is a 
primary insurance policy effective with another insurer from January 1, 2019, through July 31, 2021, 
and the Plan did not receive a copy of the explanation of benefit statement or a termination. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
 The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has not received 
a copy of the explanation of benefit statement or a termination from the primary insurer. As the secondary 
insurer, the Plan cannot be held responsible for the physician's services until the primary insurer has denied the 
claim for these services. Therefore, we decided that the Plan does not have to pay for physician's services 
provided on June 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on September 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 dental 
services on September 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Calquence (J8999). 
 
You asked the Plan to pre-approve Calquence. You say that Calquence is medically necessary. The Plan denied 
your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Calquence (J8999).  
 
Benefits for Calquence may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records document that the enrollee 
has acid reflux and an intolerance to oral bisphosphonates; however, there is no indication that the enrollee has 
tried and failed intravenous (IV) zoledronic acid. The records do not show that the IV zoledronic acid is 
contraindicated or less effective; therefore, Prolia is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electroencephalogram (EEG); recording in coma or sleep 
only provided on May 9, 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 the code is not appropriate for the services 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. 
 
In this case, the CPT Code Manual definition of code 95822 is "Electroencephalogram (EEG); recording in 
coma or sleep only." 
 
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 the EEG as reported in this case 
did not meet the minimum technical standards for an EEG as defined by the American Clinical 
Neurophysiology Society (ACNS). Nor did the report on the limited channel EEG that was performed support 
that recording was done in sleep or coma. There was no narrative provided to support such a recording haven taken plan. Furthermore, the limited nature of the EEG is not otherwise considered to be diagnostic in nature. 
In as much the code cannot be supported at this time. 
 
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 electroencephalogram (EEG); recording in coma or sleep only provided on May 9, 2022.