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

 
We decided that the Plan does not have to waive the cost share for prescription drugs, office visits, 
chemotherapy administrations, physical therapies, radiation treatments, radiation consultations, an endoscopy, 
x-rays, and nuclear diagnostic imaging provided on January 4, 2022, to November 15, 2022. 
 
You asked the Plan to waive the cost share for prescription drugs, office visits, chemo administrations, physical 
therapies, radiation treatments, CT scans, radiation consultations, endoscopy, x-rays, nuclear diagnostic. You 
say that you do not agree with the member responsibilities on these claims. 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 for each 
item or service.  
 
The EOC benefit category: Says the cost sharing is: For: 
Medicare Part B prescription drugs  20% coinsurance Drugs and IV  
Physician/practitioner services, 
including doctors office visits 
$35 copayment Per office visit 
Physician/practitioner services, 
including doctors office visits 
20% coinsurance Chemotherapy administration  
Outpatient rehabilitation services $40 copayment Per physical therapy  
Outpatient diagnostic tests and 
therapeutic services and supplies 
20% coinsurance For each radiation treatment, CT scan, 
and Radiation consultation 
Outpatient diagnostic tests and 
therapeutic services and supplies 
$35 copayment  For each endoscopy and x-ray 
Outpatient diagnostic tests and 
therapeutic services and supplies 
$100 copayment For each nuclear diagnostic imaging  
 
Your maximum out of pocket amount is $4,000. Once you have met $4,000 out of pocket amount, you would 
not pay additional charges.  
 
You have been asked to pay a total cost share of $3,842.01 for prescription drugs, office visits, chemotherapy 
administrations, physical therapies, radiation treatments, radiation consultations, an endoscopy, x-rays, and 
nuclear diagnostic imaging. The record shows that at the time these services were provided, your out-of-pocket 
maximum had not been met. 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 share for prescription drugs, office 
visits, chemotherapy administrations, physical therapies, radiation treatments, radiation consultations, an 
endoscopy, x-rays, and nuclear diagnostic imaging provided on January 4, 2022, to November 15, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99291 billed for date of service May 24, 2022. 
 
You asked the Plan to pay for code 99291. You say that this claim was for an emergency visit, so it should be 
paid. The Plan denied your request. The Plan says this code is not separately payable from code 25600-54 
billed for date of service February 24, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that that evaluation and management (E/M) services 
provided during a global period of surgery are only separately payable when billed with an appropriate 
modifier to indicate that the service is unrelated to or significant above and beyond usual post-operative work. 
The modifiers to be appended in these situations are -24 and -25.  In this case, records show that the same 
provider billed for a major surgery service (code 25600-54) on date of service February 24, 2022.  You then 
billed an E/M service (99291) on date of service May 24, 2022, which is only 89 days from the date of the 
major surgery.  The surgery (code 25600-54) has a 90-day global period.  This means that any E/M services 
that occur within the 90-day period following the surgery are only separately payable when billed with a -24 or 
-25 modifier.  You did not bill code 99291 with a -24 or -25 modifier as is required for separate payment.  
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for code 
99291 billed for date of service May 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the chest x-ray provided on September 
2, 2022, billed with code 71045. 
 
You asked the Plan to pay for the interpretation of the chest x-ray provided on September 2, 2022, billed with 
code 71045. a chest X-ray. You say that the claim was billed right and should be paid. The Plan denied your 
request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on October 4, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for a chest X-ray have not been met. Therefore, 
we decided that the Plan does not have to pay for the interpretation of the chest x-ray provided on September 2, 
2022, billed with code 71045. procedure code 71045, x-ray exam chest single view.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Angeliq. 
 
You asked the Plan to pre-approve Angeliq. You say that you would like the Plan to reconsider their denial. 
The Plan denied your request. The Plan says Angeliq is not covered under the enrollee's Medicare Part B 
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 Angeliq.  
 
Benefits for Angeliq 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Magnetic resonance imaging (MRI) of the lumbar 
spine. 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that the requested MRI of the lumbar 
spine is medically necessary. The Plan denied your request. The Plan says the requested MRI of the lumbar 
spine is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI of the lumbar spine. Our 
reviewer says that the requested MRI of the lumbar spine is not medically necessary. Our physician reviewer 
found there is no need for an updated MRI of the lumbar spine at this time for a pain management referral. A 
recent trial of physical therapy for back pain is needed. 
 
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 MRI of the lumbar spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the tetanus, diphtheria toxoids and acellular 
pertussis vaccine (Tdap) (90715), and administration (90472) provided on August 2, 2022. 
 
You asked the Plan to reimburse you for the immunization services. You say that you should be reimbursed for 
these services. The Plan denied your request. The Plan says the immunizations are not covered under Medicare 
Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunization 
services. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the immunization 
services. Therefore, we decided that the Plan does not have to reimburse you for the tetanus, diphtheria toxoids 
and acellular pertussis vaccine (Tdap) (90715), and administration (90472) provided on August 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Elitek. 
 
You asked the Plan to pre-approve Elitek. You say that the requested Elitek is medically necessary. The Plan 
denied your request. The Plan says the requested Elitek is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Elitek. Our reviewer says that the 
requested Elitek is not medically necessary. Our physician reviewer found the requested use of Elitek is not 
FDA-approved for the enrollee's diagnosis. Indicated in high-risk Chronic lymphocytic leukemia (CLL) treated 
with venetoclax and lymph node greater than or equal 10 cm or lymph nodes greater than or equal to 5 cm plus 
absolute lymphocyte count greater than or equal to 25 x 109/L, and elevated serum uric acid level. This 
enrollee does not meet this criterion. The requested use of Elitek is not supported by one of the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Elitek have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Elitek.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 2, 2021, 
through September 7, 2021, and billed with diagnosis code E87.2. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis E87.2, Acidosis is supported by the records. The Plan denied your request. The Plan says 
the documentation submitted does not support the secondary diagnosis of E87.2, Acidosis. 
 
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 secondary diagnosis code E87.2, Acidosis. 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 documentation does not support the secondary diagnosis of E87.2, 
Acidosis. Our physician reviewer found the member did not meet definition/criteria of acidosis.  
 
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 provided on September 2, 2021, through September 7, 2021, and billed with 
diagnosis code E87.2.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for maintenance chemotherapy provided in India on 
February 7, 2022. 
 
You asked the Plan to pay for the maintenance chemotherapy provided in India. You say that the services were 
medically necessary. The Plan denied your request. The Plan says the services were foreseen and expected for 
the lung cancer condition and are therefore not urgent. 
 
The Plan contract provides coverage for emergent/urgent world-wide care. The Plan says coverage is for 
urgently needed services that are non-emergency, unforeseen medical illness, injury, or condition that requires 
immediate medical care. 
 
We looked at the file and Plans rules. Based on this information, we decided that the Plans rules for coverage 
of the maintenance chemotherapy provided in India have not been met. Therefore, we decided that the Plan 
does not have to pay for maintenance chemotherapy provided in India on February 7, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from August 8, 2022 to  
August 29, 2022. 
 
You asked the Plan to pay for the psychotherapy. You say that you have previously been reimbursed for other 
providers services that do not accept Medicare assignment. The Plan denied your request. The Plan says the 
services were obtained from a provider who is not under contract with the health Plan and is not certified for 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
psychotherapy provided from August 8, 2022 to August 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 31, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
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 procedure code 70450 billed for date of service October 31, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to an IRF is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollees care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a crown (D2740), and a core build-up (D2950) provided on November 11, 2022, to December 21, 2022.

You asked the Plan to pay for a crown, and a core build-up. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the rendered dental services are not covered 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.

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 a crown (D2740), and a core build-up (D2950) provided on November 11, 2022, to December 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for echocardiography services (procedure codes 93312, 93320, 
93325) provided to the enrollee on September 5, 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 denied codes remain 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 93312: 
 
Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode 
recording); including probe placement, image acquisition, interpretation and report 
 
CPT 93320: 
 
Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in 
addition to codes for echocardiographic imaging); complete 
 
CPT 93325: 
 
Doppler echocardiography color flow velocity mapping (List separately in addition to codes for 
echocardiography) 
 
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 codes in question are not 
supported by the medical record as separately identifiable from the anesthesia. The documentation of the 
transthoracic echocardiography (TEE( is included in the anesthesia record and there is no separate report of a 
diagnostic TEE or Doppler procedure. The plan is also correct that 93320 and 93325 are add on codes and 
require a primary procedure. 
 
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 echocardiography services (procedure codes 93312, 93320, 93325) provided to the enrollee on 
September 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 29, 
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 services were not pre-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 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 laboratory services provided to the enrollee on 
August 29, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz. 
 
You asked the Plan to pre-approve Supartz. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says Supartz is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Supartz is covered when there is significant 
improvement in knee pain and known improvement in functional capacity resulted from the previous series of 
injections which has been documented in the record. 
 
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 Supartz. Our reviewer says that the 
documentation does not support that Supartz is medically reasonable or necessary. Our physician reviewer 
found the enrollee has bilateral knee pain due to osteoarthritis. The enrollee has been treated with medical 
therapy and completed a series of viscosupplementation injections in August 2022. The enrollee has continued 
bilateral knee pain and uses a cane for ambulation. However, the documentation did not show significant 
improvement in knee pain and known improvement in functional capacity resulted from the previous series of 
injections which has been documented in the record.  Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Supartz have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Supartz.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for psychotherapy provided from September 2, 2022 
to September 26, 2022. 
 
You asked the Plan to reimburse you for the psychotherapy. You say that although this provider does not 
accept Medicare, you have received reimbursement from the Plan in the past. The Plan denied your request. 
The Plan says this provider is not under contract with the health Plan and is not certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for 
psychotherapy provided from September 2, 2022 to September 26, 2022.