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

We decided that the Plan does not have to pay for the services (99214) provided on July 26, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were
billed incorrectly.
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 99214 is "Office or other outpatient visit for the
evaluation and management of an established patient, which requires a medically appropriate history and/or
examination and moderate level of medical decision making. When using time for code selection, 30-39
minutes of total time is spent on the date of the encounter."
We find that CPT code 99214 is not supported in the medical record. Specifically, the services in question were
billed with an emergency room place of service (POS 23). It is inappropriate to bill code 99214 for an
emergency department visit. There is a more appropriate code to report for these services. 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 the services (99214) provided on July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection.
You asked the Plan to pre-approve a lumbar epidural steroid injection. You say that the enrollee has tried
physical therapy and medication trials. The Plan denied your request. The Plan says the injection is not
medically necessary.
The Plan follows Medicare rules. The rules say that an ESI will be considered medically reasonable and
necessary when the above criteria are met.
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 lumbar epidural steroid injection. Our
reviewer says that a lumbar epidural steroid injection is not medically necessary. Our physician reviewer found
there is no detailed physical examination of the lumbar spine, motor, sensory and reflexes of the lower
extremities and there is no imaging pathology identified that is the pain generator for the steroid injection. The
request at this point, 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 a lumbar epidural steroid injection have not been met. Therefore, we decided
that the Plan does not have to pre-approve a lumbar epidural steroid injection.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided from November 27,
2020, through November 28, 2020.
You asked the Plan to pay for the outpatient hospital services. You say that the denial is not appropriate. The
Plan denied your request. The Plan says there is nothing payable on the claim.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that the CPT codes billed are not supported in the medical record. Specifically, the billed CPT codes
have a status indicator of N. This means that the CPT codes are incidental services and packaged for payment.
Based on this information, we decided that Medicare rules for coverage of the outpatient hospital services have
not been met. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services
provided from November 27, 2020, through November 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from September 7, 2021, to September 14, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you believe that all coronavirus related charges are fully covered. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $125 per day for days 1-10 and $0 per day for days 11-90 for each inpatient stay. The file shows that you were in the hospital from September 7, 2021, to September 14, 2021, but there is no copayment for the discharge date. Therefore, you have been asked to pay $125 per day for 7 days of inpatient
hospital services. The total for your stay is $875 ($125 per day x 7 days = $875). Please note that the file also shows that the Plan has indicated the charges for the inpatient stay did not meet coronavirus waiver criteria per the Plan guidelines. The inpatient hospital services fall 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 services provided from September 7, 2021, to September 14, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care.
You asked the Plan to pay for acute inpatient hospital care. You say that you would like reconsideration
because the inpatient hospital care is medically necessary. The Plan denied your request. The Plan says that the
member does not meet Medicare criteria for coverage of acute inpatient hospital care.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the record showed that at the time of inpatient admission the admitting physician may
reasonably expect that the member's necessary hospital care (including earlier ED and/or observation care) will
span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the trimming of non-dystrophic nails (11719) provided on November 2, 2021.
You asked the Plan to pay for the trimming of non-dystrophic nails (11719). You say that you are being charged a $100 copayment for a podiatry visit. You say that you have Type 2 diabetes and should not have a copayment for podiatry. The Plan denied your request. The Plan says you do not meet Medicare guidelines for trimming of non-dystrophic nails.
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or feet or have fungal nails. Records do not show that any of these conditions are present. The services you are asking the Plan to pay for are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the trimming of non-dystrophic nails (11719) have not been met. Therefore, we decided that the Plan does not have to pay for the trimming of non-dystrophic nails (11719) provided on November 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of intravenous immune globulin (IVIG) (Privigen).
You asked the Plan to pre-approve Privigen. You say that Privigen is medically necessary. The Plan denied
your request. The Plan says the denial of authorization for this drug is correct, because Privigen is not
medically necessary for the enrollee.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Privigen. Our reviewer says that the
enrollee does not meet the criteria for the requested use of Privigen. Our physician reviewer found the use of
intravenous immune globulin (IVIG) such as Privigen is not indicated in patients with immune
thrombocytopenic purpura (ITP) and platelet counts above 30,000 and no evidence of bleeding. IVIG is
appropriate for individuals who require a more rapid increase in platelet count, those who do not have an initial
platelet count increased with glucocorticoids, or those who require therapy to increase the platelet count and
cannot tolerate glucocorticoids. The enrollee does not require IVIG at this time and the treatment is not
medically reasonable and 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 Privigen have not been met. Therefore, we decided that the Plan does not have
to pre-approve use of intravenous immune globulin (IVIG) (Privigen).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four 2D oral/facial photographic images (D0350 x4), 
comprehensive oral evaluation (D0150), and additional intraoral periapical x-ray (D0230) provided on 
September 1, 2021.
You asked the Plan to pay for the 2D oral/facial photographic images, comprehensive oral evaluation, and 
additional intraoral periapical x-ray. You say that you would like to appeal these services. The Plan denied your 
request. The Plan says the 2D oral/facial photographic images are not covered under your plan. The Plan also 
says that you have already been reimbursed for a comprehensive oral evaluation and intraoral periapical x-ray.
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, 2D oral/facial photographic image 
(D0350) is not among those covered under this benefit. The contract says that comprehensive oral evaluation 
(D0150) is limited to one procedure code every three years. The record shows that you received a 
comprehensive oral evaluation (D0150) on August 17, 2021 and your comprehensive oral evaluation (D0150) 
benefit has been exhausted. The Plan contract also says that intraoral x-rays are limited to one procedure code 
per calendar year. The record shows that you received two additional intraoral periapical x-rays (D0230 x2) on 
September 1, 2021, one of which was covered by the Plan, and your intraoral x-rays benefit has been 
exhausted. Therefore, we decided that the Plan does not have to pay for the four 2D oral/facial photographic 
images (D0350 x4), comprehensive oral evaluation (D0150), and additional intraoral periapical x-ray (D0230) 
provided on September 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) and the laboratory service (82962) rendered by the out-of-network (OON) provider on November 1, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan 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 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 (99213) and the laboratory service (82962) rendered by the out-of-network (OON) provider on November 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on February 20, 2021.
You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contract
providers at the preferred provider rate when services are not available from preferred providers in the service
area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan
denied your request. The Plan says the code is not appropriate for the service billed.
The Plan must follow Medicare rules. The rules 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 rules also say that for Medicare to consider coverage and payment for any item or
service, the information submitted by the supplier or provider must corroborate the documentation in the
beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the physical therapy services have not been met. Specifically, medical records for the services
provided on February 20, 2021, were not submitted. This means that we could not determine if Medicare
coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for physical therapy
services provided on February 20, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital surgery services provided on October 11, 2021.
You asked the Plan to waive the copayment for the surgery services. You say that the copayment should be lowered. The surgery center is low risk and controlled environment, but the copayment is higher than the copayment for the emergency room. The Plan denied your request. The Plan says the provider billed as an outpatient facility and the proper copayment was 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 $450 copayment per visit for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.
You have been asked to pay a $450 copayment for the surgery services. The surgery services falls within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 the outpatient hospital surgery services provided on October 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an addition, endoskeletal system, below knee, alignable
system (L5910).
You asked the Plan to pre-approve an addition, endoskeletal system, below knee, alignable system. You say
that the item is medically necessary. The Plan denied your request. The Plan says you were approved for a
preparatory prosthesis (L5530) on December 9, 2021. The full description for L5530 indicates that this is a
non-alignable system. The code (L5910) is for an alignable system and cannot be used with this preparatory
prosthesis; the request does not meet medical necessity criteria.
The Plan must follow Medicare rules. Medicare rules say that when a preparatory below knee prosthesis
(L5510-L5530, L5540) is provided prosthetic substitutions and /or additional of procedures and components
are covered in accordance with the functional level assessment.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of an addition, endoskeletal system, below knee, alignable system have not been met. Therefore, we
decided that the Plan does not have to pre-approve an addition, endoskeletal system, below knee, alignable
system (L5910).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on
July 31, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you believe that all coronavirus
related charges are fully covered. The Plan denied your request. The Plan says you have been charged the
correct cost sharing 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 $120
copayment for each emergency room visit.
Please note that there are no coronavirus cost share waivers in effect. Therefore, you have been asked to pay a
$120 copayment for the ER visit. The ER visit falls within the Emergency 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 an emergency room (ER) visit provided on July 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on June 9, 2021 by a Medicare opt out provider.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you have been using this dentist twice a year for years and submitting the proper forms for reimbursement to the Plan. You also say that you have received checks from the Plan which you deposited in your bank but suddenly you are being denied. The Plan denied your request. The Plan says you received these services from a provider who chose not to receive Medicare funds.
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 covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on June 9, 2021 by a Medicare opt out provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance ride provided on June 15,
2021.
You asked the Plan to waive the copayment for an ambulance ride. You say that the urgent care facility forced
you to be transported to the emergency room by ambulance and you already had another ride. The Plan denied
your request. The Plan says the proper copayment was 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 $250
copayment for each one-way Medicare-covered ground trip.
You have been asked to pay a $250 copayment for an ambulance ride. An ambulance ride falls within the
Ambulance Services 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 ambulance ride
provided on June 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cerefolin caplets.
You asked the Plan to pre-approve Cerefolin caplets. The Plan denied your request. The Plan says this drug is
not covered for the enrollee's condition by Medicare Part B.
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 Cerefolin caplets.
Benefits for Cerefolin caplets 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit coded 99213 provided on August 3, 2021.
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 99213 is office or other outpatient visit for the evaluation
and management of an established patient, which requires a medically appropriate history and/or examination
and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is
spent on the date of the encounter.
We find that CPT code 99213 is not supported in the medical record. Specifically, the documentation shows
that this service was billed with a place of service of 23 (Emergency Room- Hospital). The documentation
shows that the enrollee was seen for an Emergency Department visit. This means this code billed was not
appropriate for the services rendered. Based on this information, we decided that Medicare rules for coverage
of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office
visit coded 99213 provided on August 3, 2021.