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

 
We decided that the Plan does not have to waive the cost share for an office visit and Medicare Part B 
prescription drug provided on September 23, 2022. 
 
You asked the Plan to waive the cost share for an office visit and Medicare Part B prescription drug. You say 
that you are disputing the share cost. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs and $35 copayment for Physician/Practitioner services, 
including doctors office visits. You have been asked to pay 20% coinsurance for Medicare Part B prescription drug and $35 copayment for an 
office visit. These items/services fall within the Medicare Part B prescription drugs and 
Physician/Practitioner services, including doctors office visits benefit categories. 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 an office visit and Medicare Part B prescription drug provided on September 23, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis and addition to lower extremity orthosis 
provided on October 4, 2022. 
 
You asked the Plan to pay for the knee orthosis and addition to lower extremity orthosis. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the items rendered are not 
supported. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Review of the file shows that the documentation does not indicate that the enrollee had knee pain 
to support the need for the orthosis provided. The record shows that the Plan made several attempts to obtain 
the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
knee orthosis and addition to lower extremity orthosis provided on October 4, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided 
on November 1, 2022, to November 21, 2022. 
 
You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you disagree 
with the copayment. 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 $40 
copayment for outpatient rehabilitation services.  
 
You have been asked to pay a $40 copayment for outpatient rehabilitation services. The total allowed amount 
for rehab services is $320 ($40 x 8 visits = $320). However, you are only being asked to pay $200 which is less 
than the required amount. 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 outpatient rehabilitation 
services provided on November 1, 2022, to November 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4556 billed for date of service July 5, 2022. 
 
You asked the Plan to pay for procedure code A4556. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code A4556 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A4556 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A4556 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4556 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4556 billed for date of service July 5, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network diagnostic duplex scan of the 
leg provided on September 7, 2022. 
 
You asked the Plan to waive the copayment for a duplex scan. You say that this should be covered as it is part 
of a surgical follow up. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
The coverage you are referencing lasts 90 days from the surgery date 
 
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 $140 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
You have been asked to pay the allowed amount of $136.83 which is less than the $140 copayment for a duplex 
scan. This item/service falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 
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 in-network diagnostic duplex 
scan of the leg provided on September 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on June 24, 2022, to 
June 30, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you want to appeal the 
amount being charged. 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 $200 
copayment per day for days 1-5 and $0 after day 5 for inpatient hospital stay. Includes inpatient acute, inpatient 
rehabilitation, long-term care hospitals and other types of inpatient hospital services. Inpatient hospital care 
starts the day you are formally admitted to the hospital with a doctors order. The day before you are 
discharged is your last inpatient day. 5 x $200 = $1,000. Therefore, results in the total cost sharing amount of 
$1,000.  
 
 
 You have been asked to pay a $200 copayment per day for inpatient hospital stay. This item/service falls within 
the inpatient hospital 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 inpatient 
hospital stay on June 24, 2022, to June 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration (D4266) and bone 
replacement graft (D7953) for tooth #2. 
 
You asked the Plan to pre-approve the dental services. You say that the dental services are medically necessary 
in order to have your teeth removed. The Plan denied your request. The Plan says the denial of authorization 
for these services is correct, because the guided tissue regeneration and bone replacement graft are not covered 
by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
guided tissue regeneration (D4266) and bone replacement graft (D7953) for tooth #2.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150-91, 87481, 87653, 87798-91, 87801-
91, 87641-91, and 87500-91 billed for date of service April 8, 2022. 
 
You asked the Plan to pay for procedure codes 87150-91, 87481, 87653, 87798-91, 87801-91, 87641-91, and 
87500-91. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your 
request. The Plan says payment for codes 87481 and 87653 are bundled into payment for codes 87150 and 
87801. Furthermore, the records do not support the use of modifier 91 billed with codes 87150, 87798, 87801, 
87641, and 87500. 
 
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 codes 
87481 and 87653 are column II codes to column I codes 87150 and 87801. This claim has not been billed with 
an appropriate modifier to bypass the edit for these codes.  
 
Medicare rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the 
intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
The records provided do not support the use of modifier 91 billed with codes 87150, 87798, 87801, 87641, and 
87500. 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 codes 87150-91, 87481, 87653, 87798-91, 87801-91, 87641-91, 
and 87500-91 billed for date of service April 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower/bath chair (E0240). 
 
You asked the Plan to pre-approve a shower chair. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower/bath chair (E0240).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services (00400) provided on March 31, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says that this code is only payable to anesthesia providers. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not fully described the reason for this denial. The provider that 
rendered this service is an anesthesia provider. Therefore, we decided that the Plan has to pay for anesthesia 
services (00400) provided on March 31, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services received on March 3,2022. 
 
You asked the Plan to pay for wound care services. The Plan denied your request. The Plan says Original 
Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for wound care services received on March 3,2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sodium bicarbonate, vitamin C, and magnesium sulfate 
infusion therapy. 
 
You asked the Plan to pre-approve sodium bicarbonate, vitamin C, and magnesium sulfate infusion therapy. 
You say that the requested sodium bicarbonate, vitamin C, and magnesium sulfate infusion therapy is 
medically necessary. The Plan denied your request. The Plan says the requested sodium bicarbonate, vitamin C, 
and magnesium sulfate infusion therapy 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 sodium bicarbonate, vitamin C, and 
magnesium sulfate infusion therapy. Our reviewer says that the requested sodium bicarbonate, vitamin C, and 
magnesium sulfate infusion therapy is not medically necessary. Our physician reviewer found the record 
indicates that the enrollee has a diagnosis of adenocarcinoma of the lung and is receiving the requested therapy 
for treatment of this condition. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a 
supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature from 
Medicare approved cancer journals were submitted for review. The elements of the coverage criteria are not 
satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sodium bicarbonate, vitamin C, and magnesium sulfate infusion therapy have 
not been met. Therefore, we decided that the Plan does not have to pre-approve sodium bicarbonate, vitamin C, 
and magnesium sulfate infusion therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service July 7, 2022, billed with code 99153. 
 You asked the Plan to pay for procedure code 99153. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says code 99153 is not payable in the facility 
setting. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service July 7, 2022, billed with 
code 99153.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 17000 and 17003 billed for date of service 
October 5, 2022. 
 
You asked the Plan to pay for procedure codes 17000 and 17003. 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 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 17000 
is a column II code to column I code 17282. This claim has not been billed with an appropriate modifier to 
bypass the edit. Furthermore, we have confirmed that code 17003 is an add-on code and as the primary 
procedure code 17000 is not covered, the add-on code is not payable. 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 codes 
17000 and 17003 billed for date of service October 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided from 
October 8, 2022, through October 11, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you were advised by your 
provider to seek emergency services; therefore, you should not have a copayment. 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 $298 
copayment per day, days 1 to 5 and $0 copayment per day, days 6-90 for in -network inpatient care. 
 
You have been asked to pay $894 for the inpatient hospital stay ($298/day x 3 days = $894). This inpatient 
hospital stay falls within the Inpatient hospital 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 inpatient hospital stay provided from October 8, 2022, through October 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on July 23, 2022, to August 01, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
July 23, 2022, to August 01, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L4-S1 lumbar decompression fusion (63017, 63030, 
221612, 22840, 20931, 76000, 63048, 22614, 22842, and 61783). 
 
You asked the Plan to pre-approve L4-S1 lumbar decompression fusion (63017, 63030, 221612, 22840, 20931, 
76000, 63048, 22614, 22842, and 61783). You say that the requested L4-S1 lumbar decompression fusion 
(63017, 63030, 221612, 22840, 20931, 76000, 63048, 22614, 22842, and 61783) is medically necessary. The 
Plan denied your request. The Plan says the requested L4-S1 lumbar decompression fusion (63017, 63030, 
221612, 22840, 20931, 76000, 63048, 22614, 22842, and 61783) is 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 L4-S1 lumbar decompression fusion 
(63017, 63030, 221612, 22840, 20931, 76000, 63048, 22614, 22842, and 61783). Our reviewer says that the requested L4-S1 lumbar decompression fusion (63017, 63030, 221612, 22840, 20931, 76000, 63048, 22614, 
22842, and 61783) is not medically necessary. Our physician reviewer found the enrollee was being treated for 
lumbar radiculopathy and bulging lumbar disc. She presented with low back pain with onset over a year ago. 
The pain is sharp and is in the lower back and radiates to the right thigh-lateral left leg to the left foot. The 
condition is overall worsening. The exam reveals strength at 4/5 bilateral dorsiflexion. 
 
However, dynamic flexion/extension films are not provided to potentially assess the amount of movement 
(instability) at the requested surgical level. Detailed documentation is not evident regarding potential 
impending/inevitable temporary intra-operative instability. The objective examination findings did not 
corroborate any significant neurological deficits that would require emergent procedure. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested L4-S1 lumbar decompression fusion (CPTs 63017, 63030, 
22612, 22840, 20931, 76000, 63048, 22614, 22842, and 61783), in this case, is not medically reasonable or 
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 L4-S1 lumbar decompression fusion (63017, 63030, 221612, 22840, 20931, 
76000, 63048, 22614, 22842, and 61783) have not been met. Therefore, we decided that the Plan does not have 
to pre-approve L4-S1 lumbar decompression fusion (63017, 63030, 221612, 22840, 20931, 76000, 63048, 
22614, 22842, and 61783).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic compressor and segmental pneumatic 
appliances for use with pneumatic compressor, full leg to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve pneumatic compressor and appliances. You say that the pneumatic 
compression device will be beneficial to the enrollee. The Plan denied your request. The Plan says the service 
can be provided by an in-network provider. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
pneumatic compressor and segmental pneumatic appliances for use with pneumatic compressor, full leg to be 
provided by an out-of-network (OON) provider.