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

 
We decided that the Plan does not have to waive the cost-sharing amounts for the outpatient office visit 
(99204) and discission of secondary membranous cataract (66821) provided on November 17, 2022. 
 
You asked the Plan to waive the cost-sharing amounts for the outpatient office visit and discission of secondary 
membranous cataract. You say that you feel the cost of the service is too much. You also say that you feel you 
are being overcharged. 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. Your 
contract with the Plan says that there is a $750 deductible which applies to outpatient surgery services. Your 
contract with the Plan also clearly says that you must pay a $35 copayment for in-person specialist visits.  
 
The discission of secondary membranous cataract (66821) you asked the Plan to waive the cost-sharing amount 
for falls within the Outpatient surgery benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $750 deductible which applies to outpatient surgery services. This cost 
sharing is a contractual obligation that had not been met at the time these services were received on November 
17, 2022. Therefore, $323.61 has been correctly applied toward the deductible. 
 
You have also been asked to pay a $35 copayment for the outpatient office visit. This service falls within the 
Physician/Practitioner 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 cost-sharing 
amounts for the outpatient office visit (99204) and discission of secondary membranous cataract (66821) 
provided on November 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99223 and 99233 for date of service July 
22, 2021, to July 23, 2021. 
 
You asked the Plan to pay for procedure codes 99223 and 99233. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and edical decision making of high 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 problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
The CPT Code Manual definition of code 99233 is subsequent hospital 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 high 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 is unstable or has 
developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the 
bedside and on the patient's hospital 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 procedure codes 99223 and 99233. Our reviewer says that 
the documentation does not support the services billed. Our reviewer found the enrollee was evaluated for 
syncope. The documentation does not support a comprehensive history and a medical decision making of high 
complexity. Therefore, code 99223 is not supported. The documentation does not support detailed interval 
history and a medical decision making of high complexity. Therefore, code 99233 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 99223 and 99233 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 99223 and 99233 for date of service July 22, 2021, to 
July 23, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for November 17, 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 procedure code 99285 is not supported by the medical records. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high 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 presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. 
 
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 these services. Our reviewer says that procedure code 99285 
is not supported by the medical records. Our reviewer found the enrollee presented to the emergency 
department with nausea and vomiting. He reported having run out of blood pressure medication. He was treated 
with Clonidine with benefit and his vitals were stable after. The workup was otherwise normal and he was 
discharged home. The documentation did not show a history or physical that was comprehensive, nor was there 
evidence of decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99285 billed for November 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic services. 
 
You asked the Plan to pre-approve chiropractic services. You say that you had a left ankle fracture surgery. 
You say that osteoarthritis formed at the surgery site, preventing you from walking with your left foot. The 
surgery caused you to walk unbalanced and you often suffer from low back and leg pain that requires frequent 
chiropractic correction. The Plan denied your request. The Plan says you do not meet criteria for approval of 
chiropractic services. 
 
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 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 chiropractic services Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you have a diagnosis of segmental 
and somatic dysfunction of lumbar and sacral regions. In 2018, you were diagnosed with lumbar radiculopathy. 
The clinical documentation does not support that you have a subluxation of the spine, demonstrated by X-ray 
or physical examination. The documentation is insufficient to demonstrate that chiropractic services are 
medically reasonable and necessary for you 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 chiropractic services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve chiropractic services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission. You say the enrollee is participating in physical therapy and wants to be able to get back to 
daily activities. The Plan denied your request. The Plan says the IRF services you are requesting do not meet 
the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99233 and 30905 billed for December 1, 
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 procedure codes 99233 and 30905 are not supported by the medical records. 
 
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 99233 is subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded. The definition of code 30905 is control 
nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; initial.  
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 these services. Our reviewer says that procedure codes 99233 
and 30905 are not supported by the medical records. Our reviewer found the enrollee was evaluated for 
epistaxis. There is no documentation of a detailed interval history and no high level decision making to support 
code 99233. There is no documentation that control of a posterior nasal hemorrhage with posterior nasal packs 
and/or cautery was performed to support code 30905 for December 1, 2022. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 99233 and 30905 billed for December 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on August 22, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 
We looked at the file and Medicare rules. Payment for the requested services (99284) is included in the global 
surgery payment for the procedure (25605) provided on August 16, 2022, which has a 90-day global period. 
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 provided on August 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98940) rendered by 
an out-of-network (OON) provider on July 18, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service was 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. 
 
You are not a network provider with the Plan. The Plan had network providers available who could have 
provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no 
exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have 
to pay for the chiropractic manipulative treatment (98940) rendered by an out-of-network (OON) provider on 
July 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on August 18, 
2022. 
 You asked the Plan to pay for the acute inpatient hospital care. You say that you strongly believe this 
admission was appropriate, and you expect full reimbursement as the services rendered could not have been 
provided in an outpatient setting. The Plan denied your request. The Plan says this stay is denied. 
 
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 the acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the record did not show that at the time of inpatient admission the 
admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier 
emergency department and/or observation care) would 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 the acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital care provided on August 18, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on September 21, 2022, billed with 
code 76706. 
 
You asked the Plan to pay for the testing services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 pay for the testing services provided. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence that the enrollee had a family history of abdominal aortic 
aneurysm, had smoked more than 100 cigarettes in his lifetime or had cardiovascular risk factors. 
 
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 testing services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for testing services provided on September 21, 2022, billed with code 76706.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. You say that the requested drug is necessary for the enrollee. The 
Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Orthovisc or 
Supartz FX. 
 
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 Euflexxa. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate the enrollee has tried and failed the preferred drugs, Orthovisc or Supartz FX. The reviewer found that 
the documentation does not support that the preferred drugs would likely be less effective, and/or would likely 
have adverse effects for the enrollee in this case. Therefore, the reviewer found that the step therapy criteria 
have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the electrodes (A4595) provided on October 4, 2022. 
 
You asked the Plan to pay for the supplies. You say that the supplies were billed correctly. The Plan denied 
your request. The Plan says that the proof of deliver is not valid. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record contains a valid proof of delivery for the supplies provided in this case. Therefore, we decided that 
the Plan has to pay for the electrodes (A4595) provided on October 4, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for the drug injection provided on June 9, 2022. We also 
decided that the Plan does not have to waive the coinsurance for the cardiac imaging and medical supplies 
provided on June 9, 2022.  
 You asked the Plan to waive the coinsurance for the cardiac imaging, medical supplies, and drug injection. You 
say that this provider should be in-network. The Plan denied your request. The Plan says that this cost sharing 
was charged correctly. 
 
We decided that the Plan has to waive the coinsurance for the drug injection.  
 
You have been asked to pay 50% coinsurance for the drug injection. According to Medicare, the injection 
(code J2785) is considered a packaged code and is not separately payable. This code is also excluded from the 
physicians free schedule. Therefore, we decided that the Plan has to waive the coinsurance for the drug 
injection provided on June 9, 2022.  
 
We also decided that the Plan does not have to waive the coinsurance for the cardiac imaging and 
medical supplies provided on June 9, 2022. 
 
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 50% 
coinsurance for out-of-network cardiac imaging. Your contract with the Plan also clearly says that you must 
pay 50% coinsurance for out-of-network medical supplies.  
 
You have been asked to pay 50% coinsurance for the cardiac imaging. You have also been asked to pay 50% 
coinsurance for the medical supplies. These items/services fall within the outpatient diagnostic tests and 
therapeutic 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 coinsurance for the cardiac imaging 
and medical supplies provided on June 9, 2022. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.