Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis code J96.01 
rendered from April 18, 2022, to April 27, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
submitted medical records for review. The Plan denied your request. The Plan says payment of DRG is not 
supported, and the review suggests that DRG 292 may be supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code J96.01. We asked our physician 
reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was 
correct in denying the request to pay for the inpatient hospital services at the DRG originally billed. Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our physician 
reviewer found that from the information that was received, documentation was inconsistent/unclear regarding 
a diagnosis of acute respiratory failure with hypoxia. In this case, there was no clinical or laboratory evidence 
of acute respiratory failure with hypoxia. The review has determined that  the documentation did not support 
J96.01.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services billed with diagnosis code J96.01 rendered from April 18, 2022, to April 27, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested 
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. You say that the chiropractic services with this provider is much more advanced and comprehensive 
as it includes decompression of spine with a combination of massage therapy. You say that you cannot receive 
this therapy in western New York, and you are trying to prolong any kind of surgery by means of alternative 
solutions including chiropractic, homeopathic, holistic, medical massage therapies inclusive of the newest 
neuromuscular therapy. The Plan denied your request. The Plan says you must receive your care from a 
network provider. In most cases, care you received from an out-of-network provider will not be 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 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on September 6, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services should not be 
included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
September 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI).  
 
You asked the Plan to pre-approve SSBCI benefits. You say that you have chronic illness and cannot move 
your right am. You also say that you have pain, live alone, and cannot do yard work by yourself. The Plan 
denied your request. The Plan says the criteria for eligibility have not been met.  
 
 
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on November 9, 2022. 
 
You asked the Plan to pay for the psychotherapy. You say that services from the same provider for previous 
dates of service were paid by the Health Plan. The Plan denied your request. The Plan says this provider is not 
part of the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist is not eligible to 
participate in the Medicare program.  
 
We looked at the file and Medicare rules. The provider at issue in this case is a Marriage Family Therapist. 
Medicare says that a Marriage Family Therapist is not eligible to participate in the Medicare program.   
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on November 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the epidural steroid injection (ESI); level C5-6 (62321). 
 
You asked the Plan to pre-approve the ESI injection. You say that the injection is medically necessary. The 
Plan denied your request. The Plan says the injection is not medically necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the ESI injection. Our physician 
reviewer found the enrollee's history, physical exam, and imaging do not support pain due to a central disc 
herniation, osteophyte or osteophyte complexes, or severe degenerative disc disease that produces foraminal or 
central spinal stenosis. The computed tomography (CT) scan showed mild degenerative disc disease in the 
lower cervical spine levels. The review has determined that the records do not support that the enrollee meets 
the coverage criteria for the epidural steroid injection. The services are 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 the ESI injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the epidural steroid injection (ESI); level C5-6 (62321).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve promethazine. 
 
You asked the Plan to pre-approve the medication. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
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 promethazine.   
Benefits for the medication 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the medical eye examination, the 
gonioscopy, and the refraction provided on January 24, 2023. 
 
You asked the Plan to waive the copayment for the vision services. You say that you were told the services 
would be covered if you went in-network. You would like to be reimbursed the $50 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 $50 
copayment for in-network Medicare-covered vision services at a specialist's office.  
 
 You have been asked to pay a $50 copayment for the vision services. The vision services fall within the vision 
care benefit category. The record shows a diagnosis of cataracts that makes the eye exam medical in nature. 
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 examination, the gonioscopy, and the 
refraction provided on January 24, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Avastin. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services were not requested with the correct J code. 
 
The Plan must follow Medicare rules. Medicare rules say that intraocular Avastin should be requested with 
code J7999. 
 
We looked at the file and Medicare rules. The file shows that Avastin was requested with code J9035 and not 
the required J7999 code. The services cannot be approved unless submitted under the correct code. Therefore, 
we decided that the Plan does not have to pre-approve Avastin.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77061 billed for date of service January 11, 
2023. 
 
You asked the Plan to pay for procedure code 77061. You say that this should be paid for. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes.  
 
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 77061 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code 77061 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 77061 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 77061 billed for date of service January 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5226). 
 
You asked the Plan to pre-approve the dental services. You say that you would like approval for this denture. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 20, 2021. Therefore, 
we decided that the Plan does not have to pre-approve a mandibular partial denture (D5226).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical shoulder arthroscopy (procedure code 29826) 
rendered on October 25, 2022. 
 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that CPT 29826 is not supported as separate and distinct procedure from CPT 23412, and should not be unbundled. 
Shoulder scope cannot be billed separately. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical shoulder arthroscopy (procedure code 29826) rendered on October 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continued inpatient level of care from June 12, 2023, 
and forward. 
 
You asked the Plan to pre-approve the continued inpatient level of care. You say that the requested 
continuation of inpatient level of care from June 12, 2023, and forward is medically necessary.  The Plan 
denied your request. The Plan says the requested continuation of inpatient level of care from June 12, 2023, and 
forward 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 the continued inpatient level of care. 
Our physician reviewer found the review has determined that the requested continuation of inpatient level of 
care from June 12, 2023, and forward is not medically reasonable or necessary for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the continued inpatient level of care have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the continued inpatient level of care from June 12, 2023, and 
forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services with an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the dental services. You say that you want to go to this provider. The Plan 
denied your request. The Plan says dental services from an out-of-network provider are not covered by your 
supplemental 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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve dental 
services with an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  partial lower denture (D5214) and partial upper denture 
(D5213). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 16, 2022. Therefore, 
we decided that the Plan does not have to pre-approve  partial lower denture (D5214) and partial upper denture (D5213).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan with CT scan for attenuation limited area. 
 
You asked the Plan to pre-approve a PET scan with CT scan for attenuation limited area. You say that the 
enrollee would like reconsideration because the services are medically necessary. The Plan denied your 
request. The Plan says a PET scan with CT scan for attenuation limited area is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a PET scan with CT scan for 
attenuation limited area. Our reviewer says that a PET scan with CT scan for attenuation limited area is not 
medically necessary. Our physician reviewer found that during the encounter on February 22, 2023, there is a 
mention of memory loss as well as an order for a PET scan with CT scan of the brain. While there were no 
further details it is required for there to be a differential diagnosis based upon historical factors between 
Alzheimer's dementia and frontotemporal disorders to qualify for a PET can with CT scan. There is no such 
differential found in this case and the PET scan with CT scan for attenuation limited area is not medically 
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 PET scan with CT scan for attenuation limited area have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a PET scan with CT scan for attenuation 
limited area.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic tests provided on 
January 24, 2023. 
 
You asked the Plan to waive the copayment for an outpatient diagnostic tests. 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 $30 
copayment for outpatient diagnostic tests/Medicarecovered non-radiological diagnostic service. 
 
You have been asked to pay a $30 copayment for an outpatient diagnostic tests. This item/service falls within 
the outpatient diagnostic tests/Medicarecovered non-radiological diagnostic service 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 outpatient diagnostic tests provided on January 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on October 04, 
2022. 
 
You asked the Plan to pay for an office visit and related services. You say that the services should be covered. 
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 an office visit and 
related services provided on October 04, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6534. 
 
You asked the Plan to pre-approve the compression stockings. You say that you need these compression 
stockings. The Plan denied your request. The Plan says A6534 is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6534 are 
noncovered because they do not meet the statutory definition of a surgical dressing.   
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6534.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
February 02, 2023, to February 28, 2023. 
 
You asked the Plan to waive the copayment for a specialist office visit. 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 $35 
copayment for physician/practitioner services/specialist. 
 
You have been asked to pay a $35 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist 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 specialist office visit provided on February 02, 2023, to February 28, 2023.