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

 
We decided that the Plan has to pay for the complicated or multiple incision and drainage of abscess 
represented by code 10061 provided on January 7, 2021. 
 
You asked the Plan to pay for code 10061. You say that the medical records support the billing of code 10061. 
The Plan denied your request. The Plan says that the medical records do not support the billing of code 10061. 
 
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 10061 is Incision and drainage of abscess (e.g., carbuncle, suppurative hidradenitis, cutaneous or 
subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple. 
 
We find that CPT code 10061 is supported in the medical record. Specifically, the Plan says that code 10060 is 
more appropriate in this case. Code 10060 is used for incision and drainage of a simple or single abscess. 
Simple lesions are typically left open to drain and heal by secondary intention. Code 10061 is used for incision 
and drainage of a complicated or multiple abscess. Complicated abscesses require placement of drain or 
packing. The record clearly shows that a local anesthetic was provided, and the abscess was incised and 
drained. The cavity was then packed with gauze. Based on this information, we decided that Medicare rules for 
coverage of code 10061 have been met. Therefore, we decided that the Plan has to pay for the complicated or 
multiple incision and drainage of abscess represented by code 10061 provided on January 7, 2021.  
 
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 must 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a problem-focused limited oral evaluation (D0140) and a 
bitewing X-ray (D0270) provided on August 5, 2021. 
 
You asked the Plan to pay for a problem-focused limited oral evaluation and a bitewing X-ray. You say that the 
services at issue should be paid because you had an emergency which was a broken tooth. The Plan denied 
your request. The Plan says rules for payment have not been met. 
 
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. The Plan covers a problem-
focused limited oral evaluation and a bitewing X-ray at a rate of one procedure each per plan year.  
 
 
  
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a problem-focused limited oral evaluation and a bitewing X-ray have not been met. Specifically, 
the Plan has documented that you have received a problem-focused limited oral evaluation and a bitewing X-
ray on prior occasions during the Plan year. Therefore, we decided that the Plan does not have to pay for a 
problem-focused limited oral evaluation (D0140) and a bitewing X-ray (D0270) provided on August 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Reblozyl injections you received on 
May 20, 2021. 
 
You asked the Plan to waive the coinsurance for the Reblozyl injections. You say that when you received these 
injections at a hospital in Manhattan, the cost was much lower. The Plan denied your request. The Plan says 
you were charged this coinsurance 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 drugs.  
 
You have been asked to pay 20% coinsurance for the Reblozyl injections. The Reblozyl injections fall within 
the Medicare Part B 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. Please note that 
when going to the hospital in Manhattan, you were receiving injections of Darbepoetin Alfa, not Reblozyl.  
These are different drugs with different prices. Therefore, we decided that the Plan does not have to waive the 
coinsurance for the Reblozyl injections you received on May 20, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency transportation in a wheelchair van (A0130) 
provided on May 12, 2021. 
 
You asked the Plan to pay for non-emergency transportation. You say that the service at issue should be 
covered according to the Plan's marketing materials. The Plan denied your request. The Plan says rules for 
payment have not been met. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers routine transportation when rides are coordinated through the Plan's transportation 
coordinator. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pay for non-emergency transportation in a wheelchair van (A0130) provided on May 12, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam provided by an out-of-network provider on 
December 3, 2020. 
 
You asked the Plan to pay for the eye exam. You say that you received a bill for $125 more so you sent the 
glasses back. You say that you told them to keep the glasses, but you haven't been refunded. The Plan denied 
your request. The Plan says this provider is not a network provider with the Plan and the services were not 
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 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 the eye exam provided by an out-of-network 
provider on December 3, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you would like to continue to stay in the skilled 
nursing facility to gain maximum function. The Plan denied your request. The Plan says that your record does 
not show that you require daily skilled nursing or skilled therapy in a SNF setting. 
 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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for continued SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the impacted cerumen removal you 
received at an outpatient hospital facility on April 30, 2021. 
 
You asked the Plan to reduce the copayment for the outpatient hospital facility services. You say that you 
should only be charged the $35 copayment for a specialist visit. The Plan denied your request. The Plan says 
you were charged this copayment correctly. The Plan says that because the allowed amount for this service 
($51.70) is less than your copayment obligation, you are responsible for the full allowed 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 $295 
copayment for outpatient surgery and other services provided at hospital outpatient facilities.  
 You have been asked to pay a $295 copayment for the outpatient hospital facility services. Records show that 
the facility where you received these services is considered an outpatient hospital facility, not a specialist's 
office. That is why these services fall within the outpatient surgery and other services provided at hospital 
outpatient facilities 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 copayment for the impacted 
cerumen removal you received at an outpatient hospital facility on April 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bilateral radiofrequency ablation of the genicular 
nerves (64624). 
 
You asked the Plan to pre-approve radiofrequency ablation of the genicular nerves. You say that the requested 
service is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage 
have not been met because the requested procedure is experimental/investigational. 
 
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 radiofrequency ablation of the genicular 
nerves. Our reviewer says that the requested services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that the requested procedure is considered an 
experimental/investigational procedure and is the subject of on-going clinical trials.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation of the genicular nerves have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a bilateral radiofrequency ablation of the genicular 
nerves (64624).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection of anesthetic agent for diagnostic or therapeutic 
purposes represented by code 64494 provided on May 24, 2021.  
You asked the Plan to pay for code 64494. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64494 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of code 
64494 have not been met. Therefore, we decided that the Plan does not have to pay for the injection of 
anesthetic agent for diagnostic or therapeutic purposes represented by code 64494 provided on May 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan and coinsurance for an injection provided on January 5, 2021.

You asked the Plan to waive the copayment for a CT scan and coinsurance for an injection. You say that you did not anticipate that you would owe this much. The Plan denied your request. The Plan says the correct charges have been applied.
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 outpatient diagnostic tests/diagnostic radiology services and a 20% coinsurance for Medicare Part B prescription drugs

You have been asked to pay a $275 copayment for a CT scan and a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $37.22. The amount being asked to pay for an injection is $7.44 ($37.22 x 20% = $7.44). The total amount you are being asked to pay is $282.44 ($275 + $7.44 = $282.44). The correct charges have been applied to the services that were provided. A CT scan falls within the outpatient diagnostic tests/diagnostic radiology services benefit category and an 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 copayment for a CT scan and coinsurance for an injection provided on January 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the medical eye exam you had on July 7, 
2021. 
 
You asked the Plan to waive the copayment for the medical eye exam. You say that you just went in for a 
routine eye exam, so there should be no copayment. The Plan denied your request. The Plan says you were 
charged this copayment 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 $10 
copayment for medical eye exams.  
 
We looked at the medical records from this service to determine what type of exam you received.  The records 
show that in addition to checking your visual acuity and getting a new eyeglass prescription, you were 
evaluated for posterior capsule opacification of the left eye and were counseled to monitor your vision changes. 
This part of the exam is not part of a routine eye exam.  That is why this eye exam is considered a medical eye 
exam and not a routine eye exam. You have been asked to pay a $10 copayment for the medical eye exam. 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 medical eye exam you had on July 7, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network outpatient mental health care provided to the
enrollee on December 2, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare coverage criteria were not met. The QIC overturned the Plans denial. The
Plan requested a reopen and provided additional information. The Plan says that here was no documented
contact with the attending or primary care physician. There is no record of a referring provider listed on the
claim. The claim records no referring physician at the appropriate location on the form.
Medicare rules say that plans can require enrollees to get care prior authorization. The contract with the Plan
says that outpatient mental health care requires prior authorization. The provider in this case is not a network
provider. The Plan did not pre-approve these services. Therefore, we decided that the Plan does not have to pay
for out of network outpatient mental health care provided to the enrollee on December 2, 2020.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the revision surgery to a reconstructed breast provided by an out-of-
network provider. 
 
You asked the Plan to pay for the revision surgery. You say that if you and the doctor's office were given the 
correct information an authorization would have been submitted. The Plan denied your request. The Plan says 
that no prior authorization was obtained. 
 
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 did not submit medical records. This means we cannot determine if the 
Plan's denial of the service is supported. Therefore, we decided that the Plan has to pay for the revision surgery 
to a reconstructed breast provided by an out-of-network provider.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computer-assisted musculoskeletal surgical 
navigational orthopedic procedure (0054T). 
 
You asked the Plan to pre-approve a computer-assisted musculoskeletal surgical navigational orthopedic 
procedure. You say that you are walking with a walker and a cane and you are in a lot of pain. You also say 
that there is a concern if your good leg gives out, it could cause more damage. The Plan denied your request. 
The Plan says the requested procedure does not meet criteria. 
 
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 a computer-assisted musculoskeletal 
surgical navigational orthopedic procedure. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found more studies are 
needed to determine operating room time, radiation exposure, and improved long-term functional outcomes 
with computer-assisted navigation (CAN). The documentation states that experimental medical and surgical 
procedures, equipment, and medications are services not covered by Medicare.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a computer-assisted musculoskeletal surgical navigational orthopedic procedure 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a computer-assisted 
musculoskeletal surgical navigational orthopedic procedure (0054T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D0210, D0330, D0150) received April 8, 2021.
You asked the Plan to pay for the dental services (D0210, D0330, D0150). You say that the provider participates in the Plan's network. The Plan denied your request. The Plan says the provider in this case does not participate in the Plan's dental network at the location where you received the services.
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 when received from a provider who does not participate in the Plan's dental network. The Plan has submitted evidence that this provider does not participate in the Plan's dental network in the location you received these services. Therefore, we decided that the Plan does not have to pay for the dental services (D0210, D0330, D0150) received April 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time over and 
above those usually included in an office visit or other non-facility service (99072) provided June 28, 2021. 
 
You asked the Plan to pay for additional supplies, equipment and staff time. You say that your medical records 
fully support and justify billing code 99072. Please see attached daily notes which clearly show what kind of 
precautions were taken by the provider of service prior to treatment the enrollee. The Plan denied your request. 
The Plan says service is considered incidental to the total episode of care. 
 
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 99072 is additional supplies, materials, and clinical staff 
time over and above those usually included in an office visit or other non-facility service. 
 
We find that CPT code 99072 is not supported in the medical record. Specifically, CMS considers these 
services bundled with the services provided to the enrollee on the same date of service and is not eligible for 
separate reimbursement. Based on this information, we decided that Medicare rules for coverage of additional 
supplies, equipment and staff time have not been met. Therefore, we decided that the Plan does not have to pay 
for additional supplies, materials, and clinical staff time over and above those usually included in an office visit 
or other non-facility service (99072) provided June 28, 2021.