Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the denosumab injection provided on 
April 15, 2021. 
 
You asked the Plan to waive the coinsurance for the denosumab injection. You say that they prescribed this 
drug because you have 10% bone loss. You say that you have a low income and were unaware this would cost 
so much. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for Medicare Part B chemotherapy prescription drugs and non-chemotherapy prescription drugs.  
  You have been asked to pay $241.08, which is 20% of the allowed amount for the denosumab injection. The 
allowed amount is $1,205.40 (20% x $1,205.40 = $241.08). The denosumab injection falls within the 
"Medicare Part B prescription drugs" 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 for 
the denosumab injection provided on April 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services coded as 28116 and 28122 provided on 
February 5, 2021, and billed with the -59 modifier. 
 
You asked the Plan to pay for the medical services as billed. You say that the documentation supports the 
services as billed. The Plan denied your request. The Plan says the documentation does not support the 
procedures as distinct and unique from what has already been paid. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
 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 medical services as billed Our reviewer 
says that the documentation does not support the use of the -59 modifier for these services. Our physician 
reviewer found that the procedure report does not include documentation to confirm CPT 28116 and CPT 
28122 are distinct procedures. Using modifier 59 properly for different anatomic sites during the same 
encounter only when procedures which are not ordinarily performed or encountered on the same day are 
performed on different organs, different anatomic regions or in limited situations on different, non-contiguous 
lesions in different anatomic regions of the same organ.  
 
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 medical services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the medical services coded as 28116 and 28122 provided on February 5, 2021, 
and billed with the -59 modifier.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (87150) provided December 10, 2020. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed 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. 
 
We find that CPT code 87150 is not supported in the medical record. Specifically, the place of service billed 
(81, lab) does not match the place of service detailed in the records (11, office setting). Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (87150) provided December 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the acute inpatient hospital care provided March 28, 2021, to 
March 30, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically 
necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. 
 
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 does not support that the criteria for inpatient payment 
are met in this case. Our physician reviewer found based on the documentation provided and history in the 
medical records, the enrollee required monitoring until blood pressure resolve with medication or intervention, 
however, she was otherwise stable and would not have been expected to require hospital services that would 
have likely crossed 2 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 not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided March 28, 2021, to March 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on July 30, 2021. 
 
You asked the Plan to pay for outpatient hospital services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent 
or emergent, nor were they approved in advance. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for outpatient hospital services provided on July 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the outpatient surgery to implant a 
defibrillator you had on May 26, 2021. 
 
You asked the Plan to waive the coinsurance for the outpatient surgery. You say that this was the second 
surgery you had to have because the first one was not successful.  You stated that you should not have to pay 
this. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan says 
that the surgery you had in January was directed towards stopping your atrial fibrillation.  This procedure was 
for the placement of a defibrillator.  The second procedure was not a 're-do' of the first. 
 
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 outpatient surgery.  
 
You have been asked to pay 20% coinsurance for the outpatient surgery. This coinsurance applies for each 
surgery you have, regardless of the reason for the surgery. 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 
for the outpatient surgery to implant a defibrillator you had on May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
June 24, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the 
enrollee on June 24, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for 
care in a SNF. The Plan denied your request. The Plan says SNF care is not medically necessary at this time. 
The Plan says that the enrollee has no decline in prior level of function. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral 
medications and had stable vital signs. The enrollee's feeding tube was replaced, and his lungs were clear. He 
was treated for herpes zoster. The enrollee received physical therapy and occupational therapy in the acute 
hospital. The enrollee was at a standby/contact guard assist to moderate assist level with functional mobility. 
The enrollee required varying assist with activities of daily living. There were identifiable skilled nursing 
service needs, but they were not required on a daily basis. There were identifiable skilled therapy service needs, 
but they also were not required on a daily basis. The enrollee does not meet the severity of illness or intensity 
of service criteria for an inpatient basis in a SNF setting. 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pathology services (87506) provided on February 24, 
2021. 
 
You asked the Plan to pay for the pathology services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says there is a more appropriate CPT code that 
should have been billed for the services provided. 
 
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 87506 is infectious agent detection by nucleic acid (DNA 
or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), 
includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple 
types or subtypes, 6-11 targets.  
We find that CPT code 87506 is not supported in the medical record. Specifically, the documentation submitted 
supports that more than 11 pathogens were the subject of the laboratory test performed. Based on this 
information, we decided that Medicare rules for coverage of the pathology services have not been met. 
Therefore, we decided that the Plan does not have to pay for the pathology services (87506) provided on 
February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for chiropractic services (including imaging) provided on May 
28, 2021. 
 
You asked the Plan to pay for services other than manual manipulation of the spine. You say that these services 
should be covered by the Plan. The Plan denied your request. The Plan says the services billed are not manual 
manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic 
services (including imaging) provided on May 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fillings for teeth # 8 and 9 provided on  
December 29, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were advised by a plan representative that 
fillings and cleanings were covered. You say that you were not advised that only 2 fillings were covered per 
year. You also say that The Plan denied your request. The Plan says 2 fillings are covered per calendar year. 
The Plan says that the frequency limit has been exceeded. The Plan also says that you were advised prior to the 
date of service that only 2 fillings were covered per calendar year. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and fillings are listed as covered, the 
frequency limit has been exceeded.  
 
 
 The record shows that the Plan paid for fillings for teeth # 20 and 21 you received on December 22, 2020. 
Therefore, we decided that the Plan does not have to pay for the fillings for teeth # 8 and 9 provided on 
December 29, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve twenty (20) additional occupational therapy (OT) visits. 
 
You asked the Plan to pre-approve additional OT. You say that additional occupational therapy visits are 
medically necessary. The Plan denied your request. The Plan says they have agreed to cover four of the 
requested twenty-four additional OT visits. However, the twenty remaining visits are denied as not medically 
necessary. You have had previous therapy and have been instructed on home exercise and home management. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 additional OT. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the additional requested therapy is not generally accepted as 
specific and effective therapy for your condition beyond what was approved by the health plan. You have had 
prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to 
safely and effectively provide treatment, or that the services can be safely and effectively performed only by a 
therapist or under the supervision of a therapist. You have been instructed in and are compliant in a home 
exercise program. Your condition is noted as stable. The requested services are not part of a maintenance 
program, and do not require specialized skill, knowledge and judgment of a qualified therapist required to 
establish, design and/or deliver a program to maintain your current condition or to prevent or slow further 
deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional OT have not been met. Therefore, we decided that the Plan does not 
have to pre-approve twenty (20) additional occupational therapy (OT) visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy. You say that the enrollee had a very rare stroke and needs 
therapy to regain function. The Plan denied your request. The Plan says the denial of authorization for 
additional physical therapy is correct, because this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy.  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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the requested therapy is not generally accepted as specific and 
effective therapy for the enrollee's condition beyond what was already approved by the Plan. The enrollee has 
had prior extensive therapy and the record does not show that the unique skills of a professional therapist are 
required to safely and effectively provide treatment or that the services can be safely and effectively performed 
only by a therapy or under the supervision of a therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services (procedure code 
 
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 appropriate modifier was not billed in this case. 
 
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 71045 is "Radiologic examination, chest; single view." 
 
We find that CPT code 71045 is not supported in the medical record. Specifically, this code cannot be billed 
separately without the appropriate modifier. 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 
imaging services (procedure code
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the injection procedure and the 
chemotherapy drugs you received on April 7, 2021, the infusion services you received on April 9, 2021, the 
injection procedure you received on April 21, 2021, and the infusion services you received on April 23, 2021, 
at an outpatient hospital facility. 
 
You asked the Plan to waive the cost sharing for the injection procedure, the infusion services, and the 
chemotherapy drugs. You say that you believe you had met your out-of-pocket maximum for the year. The 
Plan denied your request. The Plan says you were charged these cost sharing amounts correctly.  The Plan says 
that the allowed amounts for the injection procedures and the infusion services are less than your copayment 
obligations for those services, so you are responsible for the full allowed amounts for those services. The Plan 
also states that you did not hit your out-of-pocket maximum until after these claims processed. 
 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 $275 
copayment for surgery and other services at an outpatient hospital facility and 20% coinsurance for 
chemotherapy drugs.  
 
You have been asked to pay a $275 copayment for each of the injection procedure and the infusion services, 
and you have been asked to pay 20% coinsurance for the chemotherapy drugs. The injection procedure and the 
infusion services fall within the surgery and other services at an outpatient hospital facility benefit category. 
The Plan has confirmed that you did not meet your out-of-pocket maximum until after the claims for these 
services had processed. 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 cost sharing for the injection procedure and the 
chemotherapy drugs you received on April 7, 2021, the infusion services you received on April 9, 2021, the 
injection procedure you received on April 21, 2021, and the infusion services you received on April 23, 2021, 
at an outpatient hospital facility.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for X-ray transportation services (R0075) provided on  
May 26, 2021. 
 
You asked the Plan to pay for X-ray transportation services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this claim has denied correctly based 
on Medicare rules. 
 
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 looked at the file and Medicare rules. The records show that the claim for the services in dispute was billed 
with a POS code of 31.  The record indicates that the member was not in a Part A covered SNF stay on the billed date of service. There 
is a more appropriate POS code for the billed services. Therefore, we decided that the Plan does not have to 
pay for X-ray transportation services (R0075) provided on May 26, 2021.