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

 
We decided that the Plan does not have to pay for medication assisted treatment, and a take home supply of 
methadone provided on March 20, 2023. 
 
You asked the Plan to pay for medication assisted treatment, and a take home supply of methadone. You say 
that a referral, authorization, or notification is not required. 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 medication assisted 
treatment, and a take home supply of methadone provided on March 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the romosozumab injections and the 
injection administration provided on March 8, 2023, to May 9, 2023. 
 
You asked the Plan to waive the coinsurance for the injection services. You say that you were told that the 
medication would be fully covered. The Plan denied your request. The Plan says the cost sharing will be 
applied according to the Plan contract. 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 20% coinsurance for drugs covered under Medicare Part B. 
 
You have been asked to pay $418.32, which is 20% coinsurance for each injection drug provided on March 8, 
2023, and April 5, 2023 ($2,091.60 allowed amount x 20% = $418.32). You have also been asked to pay 
$415.80, which is 20% coinsurance of the allowed amount for the injection drug provided on May 9, 2023 
($2,079.00 allowed amount x 20% = $415.80). These items/services fall within the Medicare Part B 
prescription drugs 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 romosozumab 
injections and the injection administration provided on March 8, 2023, to May 9, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) provided on 
March 27, 2023. 
 
You asked the Plan to pay for the magnetic resonance angiography (MRA). You say that you are appealing the 
denial with supporting documentation. 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 magnetic resonance 
angiography (MRA) provided on March 27, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided on April 07, 2023. 
 
You asked the Plan to pay for radiology services. You say that this should be covered, you are certified in the 
state the patient is in, and no referral should be needed. 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 radiology services 
provided on April 07, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the physical therapy visit provided on 
March 10, 2023. 
 
You asked the Plan to waive the copayment for the physical therapy visit. You say that you were told that this 
service would be fully covered. 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 in-network outpatient rehabilitation services. 
 
You have been asked to pay a $40 copayment for the physical therapy visit. This item/service falls within the 
in-network 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 record shows the Plan has reprocessed the claim to show a $40 
copayment. Therefore, we decided that the Plan does not have to waive the copayment for the physical therapy 
visit provided on March 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the stab phlebectomy. 
 
You asked the Plan to pre-approve the stab phlebectomy. You say that the enrollee has moderate to severe pain 
that interferes with activities and ability to do prolonged standing. The Plan denied your request. The Plan says 
the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the treatments of the tributary veins will be 
considered medically necessary if saphenous reflux is not present or already successfully eliminated. 
 
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 stab phlebectomy. Our reviewer 
says that the requested stab phlebectomy is not medically necessary. Our physician reviewer found the 
documentation does not show that the enrollee has undergone saphenous vein reflux treatment. The Plan does 
not provide for simultaneous saphenous reflux treatment and tributary treatment. Therefore, the reviewer found 
that the stab phlebectomy 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 the stab phlebectomy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the stab phlebectomy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service May 9, 2023. 
 
You asked the Plan to pay for procedure code 83789. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 83789 is bundled into payment for code 80307. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 83789 
is a column II code to column I code 80307. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 83789 billed for date of service May 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup (D2950). 
 
You asked the Plan to pre-approve a core buildup. You say that this is a necessity they can't put a cap on 
without it. 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 
core buildup (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve add tooth to existing partial denture (D5650). 
 
You asked the Plan to pre-approve the dental services. You say that it is hard to chew, and you need this to help 
you. 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 March 21, 2023. 
Therefore, we decided that the Plan does not have to pre-approve add tooth to existing partial denture (D5650).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided by a chiropractor (99215) on March 
17, 2023. 
 
You asked the Plan to pay for the office visit. You say that you did have manipulation of the spine, and this is a 
covered benefit. The Plan denied your request. The Plan says this chiropractic service is excluded from 
coverage. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office visit provided by a chiropractor (99215) on March 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on November 07, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that you are requesting reconsideration of the 
denied claim. 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 laboratory service 
provided on November 07, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on March 14, 2023, 
to March 18, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you want someone to look 
into this and see if you can get some assistance or reduced amount. 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 $240 
copayment per day for days 1-5 for inpatient hospital care. Includes inpatient acute, inpatient rehabilitation, 
long-term care hospitals and other types of inpatient hospital services. Inpatient hospital care starts the day you 
are formally admitted to the hospital with a doctors order. The day before you are discharged is your last 
inpatient day. There were four days. 4 x $240 = $960. Therefore, results in the total cost sharing amount of 
$960. 
 
You have been asked to pay a $240 copayment per day for inpatient hospital stay. This item/service falls 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 stay on March 14, 2023, to March 18, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cerapedics I-Factor allograft (20930). 
 
You asked the Plan to pre-approve Cerapedics I-Factor allograft. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 Cerapedics I-Factor allograft. 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 compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested Cerapedics i-
Factor allograft 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 Cerapedics I-Factor allograft have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Cerapedics I-Factor allograft (20930).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on November 29, 2022. 
 
You asked the Plan to pay for the office visit. You say that you are appealing the denial with supporting 
documentation. 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 provided 
on November 29, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing (G0299 x9). 
 
You asked the Plan to pre-approve home health services. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy 
needs. The enrollee is functioning at a level commiserate with a lower 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing (G0299 x9).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery on April 24, 2023. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you say you don't know why 
you are being billed $136. 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 $365 
copayment for surgery services at outpatient hospital. Covered services include but are not limited to services 
in an emergency department or outpatient clinic, such as observation services or outpatient surgery. The 
provider billed in the amount of $275 and allowed amount is $136. This is less than the copayment amount. 
Therefore, results in the total cost sharing amount of $136. 
 
 You have been asked to pay a $136 copayment, which is less than the copayment for outpatient surgery. This 
item/service falls within the outpatient hospital 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 outpatient surgery on April 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve open repair of ruptured rotator cuff (23410). 
 
You asked the Plan to pre-approve open repair of ruptured rotator cuff. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 open repair of ruptured rotator cuff. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found no compelling rationale is presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for 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 open repair of ruptured rotator cuff have not been met. Therefore, we decided 
that the Plan does not have to pre-approve open repair of ruptured rotator cuff (23410).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99306 and 99356 for date of service May 3, 
2022, to May 4, 2022. 
 
You asked the Plan to pay for procedure codes 99306 and 99356. 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 99306 is initial nursing facility care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: 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 problem(s) requiring 
admission are of high severity. Typically, 45 minutes are spent at the bedside and on the patient's facility floor 
or unit. 
 
The CPT Code Manual definition of code 99356 is prolonged service in the inpatient or observation setting, 
requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient or 
observation Evaluation and Management service). 
 
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 99306 and 99356. Our reviewer says that 
the documentation does not support the codes billed. Our reviewer found the enrollee has a history of atrial 
fibrillation, charcot foot, neuropathy. The enrollee was admitted for gastrointestinal bleeding thought to be 
from a pyloric ulcer. The documentation does not support a comprehensive history, a comprehensive 
examination, or medical decision making of high complexity. The documentation does not support 30 minutes 
or more beyond the evaluation and management in the inpatient setting. Therefore, codes 99306 and 99356 are 
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 99306 and 99356 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 99306 and 99356 for date of service May 3, 2022, to 
May 4, 2022.