Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) and panoramic radiographic image (D0330) provided December 27, 2021. 
 
You asked the Plan to pay for the comprehensive oral exam and panoramic x-ray. You say that you cannot get 
dentures without having the exams and updated x-rays. The Plan denied your request. The Plan says you have 
exceeded the frequency limits for these services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the 
comprehensive oral exam once every three years and a panoramic x-ray once every five years. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive 
exam and panoramic x-rays were previously covered on January 23, 2020. Based on this information, we decided that the Plan's frequency limits for coverage of the comprehensive oral exam and panoramic x-ray have 
been exceeded. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation 
- new or established patient (D0150) and panoramic radiographic image (D0330) provided December 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (70450) provided on January 31, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 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 70450 
is a column II code to column I code 70496. 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 the services (70450) provided on January 31, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.  
 
You asked the Plan to pre-approve a SNF admission. The Plan denied your request. The Plan says skilled 
nursing facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from December 2, 
2021, to June 1, 2022. The Plan has covered over 100 days (105) of SNF care.  
 
 
  Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer Smart cardiac contractility modulation 
(CCM) system. 
 
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 services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found while clinical studies led to Food and 
Drug Administration (FDA) approval of the Optimizer Smart device in 2019, the device remains the subject of 
multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded trials to 
quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume 
clinical outcomes and benefit. The Optimizer Smart device is not reasonable or medically necessary at this 
time. 
 
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 an Optimizer Smart cardiac contractility modulation (CCM) system.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for psychotherapy office visits provided on 
November 2, 2021, and November 3, 2021. 
 
You asked the Plan to waive the copayment for psychotherapy office visits. You say that previously you have 
not been charged a copayment, so you are wondering if a different billing code was used. The Plan denied your 
request. The Plan says coinsurance is correct. 
 
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 $40 
copayment for each in-network, Medicare-covered group outpatient substance abuse session.  
 You have been asked to pay $80 for psychotherapy office visits ($40/visit x 2 = $80). Psychotherapy office 
visit falls within the Outpatient substance abuse 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 psychotherapy office visits provided on November 2, 2021, and November 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on October 13, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the specialist office visit. You say that you would like the medical records 
reviewed for medical necessity. The Plan denied your request. The Plan says the rendering provider is an OON 
provider and there was no referral from an in-network provider or an approved authorization. Also, the service 
rendered was not urgent or emergent. 
 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 a specialist office visit provided on October 13, 
2021, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services (99285) provided 
on October 9, 2021. 
 
You asked the Plan to pay for the evaluation and management services as billed. You say that you would like 
this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says the 
documentation does not support that the correct code was billed based on the services rendered. 
 
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 evaluation and management services as billed. Our 
reviewer says that the documentation does not support the evaluation and management services coded 99285. 
Our reviewer found that the enrollee was a then 45-year-old female with a history of obesity, diabetes mellitus, 
anxiety/depression, anemia and an abnormal R tympanic membrane who presented to the emergency 
department on October 9, 2021, and was evaluated and treated for pyelonephritis. She was treated with 
intravenous (IV) fluids, IV Ceftriaxone, IV Zofran and IV Ketorolac. Her condition stabilized and improved, 
and she was discharged home on oral antibiotics the same day. The review has determined that the 
documentation did not support the provider billing 99285 for the services rendered. Specifically, the presenting 
problems were not of high severity and did not pose an immediate significant threat to life or physiologic 
function. 
 
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 evaluation and management services as billed have not been met. Therefore, 
we decided that the Plan does not have to pay for the evaluation and management services (99285) provided on 
October 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (70450) provided on January 22, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 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 70450 
is a column II code to column I code 70496. 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 the services (70450) provided on January 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for intravenous (IV) infusions and an immune 
globulin injection provided on December 6, 2021. 
 
You asked the Plan to reduce the cost share for IV infusions and an injection. You say that you have had this 
procedure multiple times and only was charged around $100. 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 20% 
coinsurance for in-network Part B drugs. The contract also says for the administration of that drug, you will 
pay the cost-sharing that applies to depending on where you received drug administration or infusion services. 
The Plan contract also says that enrollees must pay a $350 copayment for in-network outpatient surgery or 
other services provided at an outpatient hospital. 
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
$533.76, which is 20% coinsurance of the allowed amount for an injection ($2,668.80 allowed amount x 20% 
coinsurance = $533.76). An injection falls within the Medicare Part B Prescription Drugs benefit category. 
 
You have been asked to pay the allowed amount of $202.49, which is less than the $350 copayment for IV 
infusion (code 96365). You have also been asked to pay the allowed amount of $79.60, which is less than the 
$350 copayment for IV infusion (code 96366). You have been asked to pay a total of $815.85 ($533.76 
coinsurance + $202.49 copayment + $79.60 copayment = $815.85). IV infusions fall 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 cost share for intravenous (IV) infusions 
and an immune globulin injection provided on December 6, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the OT visits provided on September 2, 
2021, and September 20, 2021. 
 
You asked the Plan to waive the copayment for the OT visits. You say that you already paid a $20 copayment 
at the time of your visits. 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 $35 
copayment for Medicare-covered Occupational Therapy visits.  
 
 
  You have been asked to pay a total of $70 ($35 copayment x 2 visits) for the OT visits. The OT visits falls 
within the Outpatient Rehabilitation 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 the OT visits provided on September 2, 2021, and September 20, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services (99285) provided 
on October 7, 2021. 
 
You asked the Plan to pay for the evaluation and management services. You say that you would like this claim 
reprocessed based on the medical records. The Plan denied your request. The Plan says the documentation does 
not support the criteria for billing CPT 99285. 
 
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 evaluation and management services. Our reviewer says 
that the documentation does not support CPT code 99285 as billed for the services that were rendered. Our 
reviewer found the review indicates that the enrollee was a then 65-year-old female who was evaluated in the 
emergency department on October 7, 2021, for increased shortness of breath. She has a history of chronic 
obstructive pulmonary disease (COPD) and had been evaluated in the emergency department 6 days prior. She 
was evaluated and treated for an exacerbation of COPD. The review has determined that the billed evaluation 
and management code 99285 was not supported by the medical documentation. Specifically, the member's 
presentation did not meet imminent danger to life or function criteria that is required for billing CPT 99285. 
 
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 evaluation and management services have not been met. Therefore, we 
decided that the Plan does not have to pay for the evaluation and management services (99285) provided on 
October 7, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
August 22, 2021. 
 
You asked the Plan to waive the copayment for an ER visit. 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 $90 
copayment for an emergency room visit.  
 
You have been asked to pay a $90 copayment for an ER visit. An ER visit falls within the Emergency 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 an emergency room (ER) visit 
provided on August 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging. 
 
You asked the Plan to pre-approve myocardial perfusion imaging. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
criteria for this testing. 
 
The Plan follows Medicare rules. Medicare rules state that myocardial perfusion imaging outpatient stress 
testing may be covered under certain circumstances. 
 
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 myocardial perfusion imaging. Our 
reviewer says that the enrollee does not meet the Medicare criteria for myocardial perfusion imaging. 
 Our physician reviewer found there is no documentation that the electrocardiogram (EKG) shows an 
uninterpretable pattern. There is no evidence that would support the need for radionuclide stress testing. There 
is insufficient documentation to support the medical necessity for cardiac stress testing in the enrollee's clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of myocardial perfusion imaging have not been met. Therefore, we decided that 
the Plan does not have to pre-approve myocardial perfusion imaging.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Nursing facility care provided on June 11, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Nursing facility care. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services can be received in-network. 
 
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 Nursing facility care provided on June 11, 2021 by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist 
device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all 
components, and accessories, custom fabricated (L8702). 
 
You asked the Plan to pre-approve a powered upper extremity range of motion assist device. You say that the 
enrollee has tried and failed physical and occupational therapies. It is the medical opinion of the enrollee's 
provider that without further intervention he will remain without meaningful use of his left upper extremity. 
The Plan denied your request. The Plan says the requested item does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in 
the patients medical record adequately supports the medical necessity for the item. 
 
The records show that the provider did not evaluate the enrollee. The record does not contain relevant medical 
records which support medical necessity for the supplies provided in this case. Specifically, the available 
records do not discuss the items at issue, document any recent attempts at therapy or records from the failed 
therapy. Therefore, we decided that the Plan does not have to pre-approve a powered upper extremity range of 
motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, 
all components, and accessories, custom fabricated (L8702).