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

 
We decided that the Plan does not have to pay for the resin-based composite on tooth #2 (D2392) and the 
posterior resin-based composite on tooth #29 provided by a network provider on January 5, 2022. 
 
You asked the Plan to pay for the resin-based composite on tooth #2 (D2392) and the posterior resin-based 
composite on tooth #29 (D2391). You say that you were told by the dental office that most of the procedures 
would be covered by your dental insurance. The Plan denied your request. The Plan says the 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 Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the resin-based composite on tooth #2 
(D2392) and the posterior resin-based composite on tooth #29 are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pay for the resin-based composite on tooth #2 (D2392) 
and the posterior resin-based composite on tooth #29 provided by a network provider on January 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services provided on March 4, 2021. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the code cannot 
be verified. 
 
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 43610 is excision, local; ulcer or benign tumor of 
stomach. We find that CPT code 43610 is not supported in the medical record. Specifically, the billed code is 
not described in the medical records provided. Providers should report services with the most comprehensive 
code available.  Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for the surgery services provided on March 4, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary due to the medical 
condition you have that effects the hands and feet. The Plan denied your request. The Plan says this item is not 
a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and related services provided on January 20, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the services were medically necessary to the 
enrollee. The Plan denied your request. The Plan says the services were not urgent, emergent, or 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 file shows the enrollee was seen for sciatic pain. The provider in this case is not a network provider with 
the Plan. The Plan had network providers available who could have provided the services at issue in this 
appeal. 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 the office visit and 
related services provided on January 20, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the chiropractic services. 
 
You asked the Plan to pre-approve the chiropractic services. You say that the service is medically necessary. 
The Plan denied your request. The Plan says this is not a covered service. 
 
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 pre-approve the chiropractic services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 7, 2022. 
 
You asked the Plan to pay for the office visit. You say that the service is not showing as the enrollee's 
responsibility. The Plan denied your request. The Plan says the claim was processed correctly. 
 
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.  
 
We looked at the file and the rules. The office visit, when billed by a chiropractor, is not a covered benefit. 
Therefore, we decided that the Plan does not have to pay for the office visit provided on January 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for Computed Tomography (CT) scan provided 
on February 1, 2022. 
 
You asked the Plan to waive the deductible for CT scan. You say that you are not responsible for this bill. The 
Plan denied your request. The Plan says coinsurance is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $300 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Annual Deductible benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $300 
deductible which applies to CT scan. This cost sharing is a contractual obligation that had not been met at the 
time CT scan was received on February 1, 2022. Therefore, we decided that the Plan does not have to waive the 
deductible for Computed Tomography (CT) scan provided on February 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for advance care planning (99497) provided on September 3, 
2021. 
 You asked the Plan to pay for advance care planning. You say that the code at issue was billed appropriately as 
a separate service. The Plan denied your request. The Plan says rules for payment have not been met because 
the code at issue is inclusive to another billed code. 
 
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 99497 is a column II code to column I code 99291; however, 99497 
was billed with a modifier.  
 
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 advance care planning. Our reviewer says that the code at 
issue does not meet criteria for reimbursement. Our reviewer found that billing guidelines indicate not to report 
advance care planning (ACP) services when: ACP services are 15 minutes or less; or ACP services are part of a 
cognitive impairment evaluation (G0505); or when critical care services (99291 - 99292) are reported by the 
same qualified health professional on the same day. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of advance care planning have not been met. Therefore, we decided that the Plan 
does not have to pay for advance care planning (99497) provided on September 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the X-ray exam of the chest (71045) provided on January 16, 
2022. 
 
You asked the Plan to pay for the X-ray exam of the chest. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this claim has not been billed as 
required by Medicare billing regulations. 
 
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. In this case, this claim was billed with an 
outpatient place of service. However, the enrollee was inpatient on the date of the service. Based on this 
information, we decided that Medicare rules for coverage of the X-ray exam of the chest have not been met. Therefore, we decided that the Plan does not have to pay for the X-ray exam of the chest (71045) provided on 
January 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit provided on October 31, 
2021. 
 
You asked the Plan to pay for the emergency department visit. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the provider is unable to received payment 
from Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the emergency department visit provided 
on October 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services in a nursing facility 
(99309) provided on December 2, 2021. 
 
You asked the Plan to pay for evaluation and management services in a nursing facility. You say that you have 
provided records to support the service billed. The Plan denied your request. The Plan says rules for payment 
have not been met. 
 
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 99309 is "Subsequent nursing facility care, per day, for 
the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient has 
developed a significant complication or a significant new problem. Typically, 25 minutes are spent at the bedside and on the patient's facility floor or unit." 
 
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 evaluation and management services in a nursing facility. 
Our reviewer says that the code at issue does not meet criteria for reimbursement. Our reviewer found that the 
documentation submitted was reviewed and the evaluation and management services provided do not support 
code 99309. In this case CPT code 99308 would be supported by documentation instead. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of evaluation and management services in a nursing facility have not been met. 
Therefore, we decided that the Plan does not have to pay for evaluation and management services in a nursing 
facility (99309) provided on December 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hotel lodging provided on January 5, 2022 to January 10, 
2022. 
 
You asked the Plan to pay for hotel lodging. You say that the service at issue should be covered because it was 
a hospital requirement. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the Plan must provide reasonable 
accommodations for the enrollee and a companion while in the distant location for transplant services. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of hotel lodging have not been met. Specifically, Medicare only provides accommodations for 
transplant services. Medicare does not cover accommodations for any other type of surgery. In this case, the treatment you received was not a transplant. Therefore, we decided that the Plan does not have 
to pay for hotel lodging provided on January 5, 2022 to January 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic panel testing provided on October 8, 2021. 
 
You asked the Plan to pay for genetic testing. You say that this testing is useful for patients at initial diagnosis 
or for a patient with refractory disease. The Plan denied your request. The Plan says the denial of payment for 
this testing is correct, because a panel constitutes a single procedural service so one code must be submitted for 
the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that if a lab procedure produces multiple reportable 
test results, only a single procedure code shall be reported for the procedure.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this 
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for genetic panel testing provided on October 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain 
rendered on January 27, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are 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 CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered 
on January 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management (99239) provided on 
May 6, 2021. 
 
You asked the Plan to pay for hospital discharge day management (99239). You say that the medical records 
support the claim was originally billed and is considered medically necessary. You say that the services were 
provided in good faith that the provider would be reimbursed, and the claim should be reprocessed for 
payment. The Plan denied your request. The Plan says the submitted discharge summary does not support 
hospital discharge day management of more than 30 minutes was performed. 
 
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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the medical records do not 
document that discharge management services or more than 30 minutes was provided as required by the CPT 
code billed. Based on this information, we decided that Medicare rules for coverage of hospital discharge day 
management (99239) have not been met. Therefore, we decided that the Plan does not have to pay for hospital 
discharge day management (99239) provided on May 6, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia services rendered on October 20, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the code is not eligible for payment. 
 
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 states that the services are not payable because anesthesia services are 
reimbursed to anesthesia providers only; however, the National Provider Identifier (NPI) for the billing 
provider shows that they are registered as an anesthesiology provider. The Plan has not provided any Medicare 
rules or documentation to support that the services are not payable as billed. Therefore, we decided that the 
Plan has to pay for the anesthesia services rendered on October 20, 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a raised toilet seat. 
 
You asked the Plan to pay for a raised toilet seat. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat 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 pay for a raised toilet seat.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Renflexis (Q5104). 
 
You asked the Plan to pre-approve Renflexis. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been 
met. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Renflexis. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of the Plan's preferred drugs Remicade, Inflectra, or Simponi Aria and a trial of preferred 
drug Stelara before they will approve the requested drug, Renflexis. Based on the medical records provided, 
there is no indication that the enrollee has tried and failed the required drugs. There is no indication that the 
Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Renflexis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Renflexis (Q5104).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia subcutaneous solution prefilled syringe 60 
mg/mL. 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says you do not meet the 
step therapy criteria requirements. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically reasonable and necessary. Our physician reviewer found there is no indication that you have tried 
and failed the required drug, Zoledronic acid. Our reviewer also found that there is no indication that the Plan's 
required drug would likely be less effective and/or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia subcutaneous solution prefilled syringe 60 mg/mL.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction (92015), provided on January 19, 2022. 
 
You asked the Plan to pay for an eye refraction. You say that the service should be covered. The Plan denied 
your request. The Plan says you received this service during a medical exam and not a routine eye exam. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when obtained during a routine eye exam. 
 
We looked at the file and the Plan's rules. You received an eye refraction during a medical exam and not a 
routine eye exam which is not a covered benefit. Based on this information, we decided that the Plan's rules for 
coverage of an eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for 
an eye refraction (92015), provided on January 19, 2022.