Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for five units of procedure code 28122 rendered on November 
17, 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 there is a more appropriate code to use for the procedure 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 28122 is Partial excision (craterization, saucerization, 
sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing); tarsal or metatarsal bone, except talus 
or calcaneus. 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that CPT code 28122 (any units) is 
not supported. The operative report states that a transmetatarsal amputation was performed. There is a more 
specific code to report this procedure. Procedures must be coded to the highest specificity.  
 
We looked at this coder'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 five units of procedure code 28122 rendered on November 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and x-ray provided on March 09, 2023. 
 
You asked the Plan to pay for the office visit and x-ray. You say that you are requesting reconsideration due to 
medical necessity. 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 the office visit and x-ray 
provided on March 09, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network emergency room (ER) visit 
provided on March 14, 2023, to March 15, 2023. 
 
You asked the Plan to waive the copayment for an in-network emergency room (ER) visit. You say that you 
had a terrible experience at this hospital and feel you should not have to pay this 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 $95 
copayment for emergency care. 
 
You have been asked to pay a $95 copayment for an in-network emergency room (ER) visit. This item/service 
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 in-network emergency room (ER) visit provided on March 14, 2023, to March 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service February 7, 
2023.  
 
You asked the Plan to pay for procedure code 88341. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed 14 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service February 7, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on March 21, 2023. 
 
You asked the Plan to pay for home health services. You say that you are appealing the claim payment denial. 
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 home health services 
provided on March 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination provided on 
February 23, 2023. 
 
You asked the Plan to waive the copayment for a medical eye examination. You say that you feel you should 
not owe the copayment when you were not given satisfactory service. 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 $40 
copayment for medical eye exam. 
 
You have been asked to pay a $40 copayment for a medical eye examination. This item/service falls within the 
medical eye exam 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 medical eye 
examination provided on February 23, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit provided 
on April 03, 2023, to April 27, 2023. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) visit. You say that you should not 
have to pay a copayment for scheduled sessions. 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 $20 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $20 copayment for each physical therapy (PT) visit. This item/service falls 
within the outpatient rehabilitation 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. The total copayment you owe is $160 for PT services ($20 per visit x 8 
visits = $160). Therefore, we decided that the Plan does not have to waive the copayment for each physical 
therapy (PT) visit provided on April 03, 2023, to April 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99292 billed for January 22, 2023. 
 
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 99292 is 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 99292 is critical care, evaluation and management of the 
critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for 
primary service). 
 
We find that CPT code 99292 is not supported in the medical record. Specifically, there is no documentation of 
an additional 31 minutes of critical care services for the date of service at issue. 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 99292 billed for January 22, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Computed tomography (CT) and laboratory service billed 
under 82565 provided on March 14, 2023. 
 
You asked the Plan to pay for Computed tomography (CT) and laboratory service billed under 82565. You say 
that you are appealing the claim payment denial. 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 Computed tomography 
(CT) and laboratory service billed under 82565 provided on March 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a periodic oral evaluation (D0120), bitewing x-rays 
(D0274), and an adult prophylaxis (D1110). 
 
You asked the Plan to pre-approve the dental services. You say that this provider has been your dentist for 
years. 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 a periodic 
oral evaluation (D0120), bitewing x-rays (D0274), and an adult prophylaxis (D1110).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric treatment from August 19 - 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric treatment. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric treatment. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based upon review 
of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health 
treatment beyond the date in question of August 19, 2023, forward and could have been treated in a lesser 
restrictive setting. He was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, or 
delusions. He was not showing any behaviors or aggression He was being cooperative and compliant while not 
showing any acute threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric treatment from August 19 - forward.
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 have been wearing 30/40mg 
compression stockings for 20 years. You also say that you have Antiphospholipid Antibody Syndrome and they 
help to decrease edema and blood clotting in both legs. The Plan denied your request. The Plan says certain 
compression garments or wraps are covered by Medicare and only when used to hold a dressing over an open 
wound or to prevent thick scars in burn patients.  
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  a cone beam CT scan (D0364), an extraction of tooth 
#17 (D7230) and the collection of autologous blood concentrate product (D7921). 
 
You asked the Plan to pre-approve these dental services. You say that this should be covered. The Plan denied 
your request. The Plan says this is not a covered service. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve  a 
cone beam CT scan (D0364), an extraction of tooth #17 (D7230) and the collection of autologous blood 
concentrate product (D7921).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy provided July 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were unaware you reached your dental 
maximum annual amount. 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 August 8, 2022. The Plan 
processes claims as they are received - the claim for the August 8, 2022 was processed prior to the claim for the date of service at issue Therefore, we decided that the Plan does not have to pay for endodontic therapy 
provided July 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing with supporting 
medical records. The Plan denied your request. The Plan says admission to an LTACH is not medically 
necessary.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no documentation provided indicating the medical necessity for 
admission to an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. There are 
no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the Plan. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on March 03, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you were 
given inaccurate information by the Plan and should not be responsible for the copayment applied. 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 $110 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $110 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic tests 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. The total you owe is $94.11, which is less than the standard copayment for a CT 
scan. Therefore, we decided that the Plan does not have to waive the copayment for a computed tomography 
(CT) scan provided on March 03, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for progressive lenses (V2781), photochromatic tint 
(V2744), lenses (V2783), anti-reflective coating (V2750), deluxe lens feature (V702), and a miscellaneous 
vision item or service (V2799) provided on April 11, 2023. 
 
You asked the Plan to pay more for progressive lenses (V2781), photochromatic tint (V2744), lenses (V2783), 
anti-reflective coating (V2750), deluxe lens feature (V702), and a miscellaneous vision item or service 
(V2799). You say that the final cost is way higher than presented to you. The Plan denied your request. The 
Plan says you are responsible for any amount over the $200 retail price. The Plan that the $200 allowance was 
deducted. 
 
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 offer a $200 benefit toward the purchase and fitting of eyeglasses. 
 
We looked at the file and the Plan's rules. The Plan rules say that they offer a $200 benefit toward the purchase 
and fitting of eyeglasses (1 per calendar year). The Plan rules also say that you are responsible for any amount 
over the $200 retail price. The record shows that is benefit was applied and exhausted to this same date of 
service. Based on this information, we decided that the Plan's rules for coverage of progressive lens (V2781), 
photochromatic tint (V2744), lenses (V2783), anti-reflective coating (V2750), deluxe lens feature (V702), and 
miscellaneous vision item or service (V2799) have not been met. Therefore, we decided that the Plan does not 
have to pay more for progressive lenses (V2781), photochromatic tint (V2744), lenses (V2783), anti-reflective 
coating (V2750), deluxe lens feature (V702), and a miscellaneous vision item or service (V2799) provided on 
April 11, 2023.  
 
Your complaint about potentially being misled about the cost of the eyeglasses is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of the neck spine, chest spine and brain to be 
provided by an OON provider.  
 
You asked the Plan to pre-approve MRI of the neck spine, chest spine and brain. You say that you do not agree 
with the denial of the requested MRI's. The Plan denied your request. The Plan says the service can be provided 
by an in-network provider. 
  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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
MRI of the neck spine, chest spine and brain to be provided by an OON provider.