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

 
We decided that the Plan does not have to pay for the evaluation and management services described by code 
99291-57 billed for date of service March 6, 2023.  

You asked the Plan to pay for 99291-57. You say that 99291-57 should be paid as billed because it is supported 
with the modifier and there is a separate diagnosis code assigned for each procedure. The Plan denied your 
request. The Plan says 99291-57 is denied because it is included in the global surgery package for code 27250 
and was not billed with an appropriate modifier to allow separate payment. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier -57 is not used with minor surgeries. 
The decision to perform the minor procedure is typically done immediately before the minor surgery and is 
considered a routine preoperative service and a visit or consultation is not billed in addition to the procedure. 
 
We looked at the file and Medicare rules. In this case, we have confirmed that 99291 with modifier -57 
appended was billed on the same day as the procedure described by code 27250, performed by the same 
provider. Modifier -57 is used to indicate that evaluation and management services on the day before major 
surgery or on the day of major surgery resulted in the decision to perform that major surgery. We have 
confirmed that 27250 has a global surgery indicator of 000, which means it is classified as a minor procedure, 
rather than a major surgery. Per Medicare rules, the decision to perform a minor procedure is included in 
payment for the procedure and modifier -57 is not used with minor surgeries. Based on this information, we 
decided that Medicare rules for coverage of 99291-57 have not been met. Therefore, we decided that the Plan 
does not have to pay for the evaluation and management services described by code 99291-57 billed for date of 
service March 6, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital inpatient or observation discharge day 
management (99239) provided on July 28, 2023. 
 
You asked the Plan to pay for the hospital inpatient discharge. You say that the service billed was correct and 
should be paid. The Plan denied your request. The Plan says the documentation does not support code 99239. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate Current Procedural Terminology CPT code. 
 
In this case, the CPT Code Manual definition of code 99239 is hospital inpatient or observation discharge day 
management; more than 30 minutes on the date of the encounter.  
We looked at the file and Medicare rules. We find that there is no information in the medical record which 
details the time spent providing discharge day management. Without this information, we cannot verify that a 
time-based code such as 99239 is supported for reporting. Based on this information, we decided that Medicare 
rules for coverage of the hospital inpatient discharge have not been met. Therefore, we decided that the Plan 
does not have to pay for the hospital inpatient or observation discharge day management (99239) provided on 
July 28, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied home health services and that the services requested 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 provided 
records do not document any acute or unstable medical conditions or changes in medication or treatment which 
would necessitate any further skilled nursing visits. 
 
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 services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Simponi Pen Injector. 
 
You asked the Plan to pre-approve the medication. You say that the medication has proven to be effective in 
the enrollee's treatment plan. 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 Simponi Pen Injector.  
 
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 pay for periapical first x-ray (D0220) and to waive the coinsurance 
for a root canal on the molar (D3330) provided on May 25, 2023. 
 
You asked the Plan to pay for the dental services. You say that you do not believe you should have to be 
responsible for this.  The Plan denied your request. The Plan says your benefit for periapical first x-ray 
(D0220) has already been exhausted. The Plan also says this cost sharing for a root canal on the molar (D3330) 
was charged correctly. 
 
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 periapical first x-ray (D0220) was exhausted on date of service August 16, 2023.  
 
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% in 
coinsurance for a root canal on the molar (D3330). 
 
You have been asked to pay $163.60 in coinsurance, which is 20% of the allowed amount for a root canal on 
the molar (D3330) ($818 x 20% = $163.60). This item/service falls within the endodontics 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 pay for periapical first x-ray (D0220) and to waive the coinsurance for a root canal on 
the molar (D3330) provided on May 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power standing system (E231), armrest pouch left 
(K0108), push handles (K0108), foot plates (K0108), cushion liner and replacement cover (K0108). 
 
You asked the Plan to pre-approve a power standing system, armrest pouch, push handles, foot plates, cushion 
liner and replacement cover. You say that the items are necessary. The Plan denied your request. The Plan says 
the power standing system, armrest pouch, and push handles are not primarily medical in nature. The foot 
plates are miscoded and the request for a cushion liner and replacement cover is unbundled. A cover is included 
in the already approved seat cushion. Therefore, coverage criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power standing system (E231), armrest pouch left 
(K0108), push handles (K0108), foot plates (K0108), cushion liner and replacement cover (K0108).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy (PT) services. 
 
You asked the Plan to pre-approve the therapy services. You say that the services are helpful in treating your 
condition. The Plan denied your request. The Plan says 4 visits have been approved; the remaining 8 visits have 
been denied as not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific 
and effective therapy for your condition beyond what was approved by the health plan. The records do not 
demonstrate that the unique skills of a professional therapist are required to safely and effectively provide 
treatment, that the services can be safely and effectively performed only by a therapist, or by or under the 
supervision of a therapist. The requested services are not part of a maintenance program, and the specialized 
skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a 
program to maintain your current condition or to prevent or slow further deterioration. You have had 
instruction in a home exercise program. The requested additional therapy sessions do not require ongoing 
skilled professional therapy. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 8 additional physical therapy (PT) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a total electric hospital bed (E0265) provided on May 25, 
2022, to November 24, 2022. 
 
You asked the Plan to pay for a total electric hospital bed. You say that the requested bed was necessary due to 
your medical condition. The Plan denied your request. The Plan says due to the height adjustment feature, total 
electric beds will be denied as not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pay for a total electric hospital bed 
(E0265) provided on May 25, 2022, to November 24, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy (PT) services. 
 
You asked the Plan to pre-approve the therapy services. You say that your condition is improving, and the 
continued therapy is needed. The Plan denied your request. The Plan says 4 visits have been approved; the 
remaining 8 visits have been denied as not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific 
and effective therapy for your condition beyond what was approved by the health plan. The records do not 
demonstrate that the unique skills of a professional therapist are required to safely and effectively provide 
treatment, that the services can be safely and effectively performed only by a therapist, or by or under the 
supervision of a therapist. The requested services are not part of a maintenance program, and the specialized 
skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a 
program to maintain your current condition or to prevent or slow further deterioration. You have had 
instruction in a home exercise program. The requested additional therapy sessions do not require ongoing 
skilled professional therapy. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 8 additional physical therapy (PT) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone marrow aspiration and a bone allograft. 
 
You asked the Plan to pre-approve a bone marrow aspiration and a bone allograft. The Plan denied your 
request. The Plan says a bone marrow aspiration and a bone allograft are 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 a bone marrow aspiration and a bone 
allograft. Our reviewer says that a bone marrow aspiration and a bone allograft are not medically necessary. 
Our physician reviewer found there is no specific indication provided to support the request for bone marrow 
aspirate for the for the approved surgery. Also, there is a lack of large volume, long-term peer-reviewed 
outcome studies to support the use of bone marrow aspirate for this enrollee's medical condition. Additionally, 
there is limited published, large-scale, long-term peer-reviewed literature that shows this requested allograft to 
be an effective and safe treatment for the noted pathology. Therefore, the requested bone marrow aspirate and 
bone 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 a bone marrow aspiration and a bone allograft have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a bone marrow aspiration and a bone allograft.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service July 13, 
2023. 
 
You asked the Plan to pay for the billed code. You say that testing was needed to monitor possible opioid 
abuse. The Plan denied your request. The Plan says the code cannot be separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. We find that the testing described by code 83789 is considered 
specimen validity testing which is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the billed code have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 83789 billed for date of service July 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on August 1, 
2023. 
 
You asked the Plan to pay for the limited oral evaluation. You say that you did not go to your primary doctor as 
you were in severe pain. You say that the provider determined you have a gum infection and require surgery. 
You also say that you would like some help with these services. The Plan denied your request. The Plan says 
the limited oral evaluation is not listed as a covered benefit.  

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the limited oral evaluation is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation (D0140) provided on August 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99070 billed for date of service October 6, 
2023. 
 
You asked the Plan to pay for procedure code 99070. You say that the claim should be paid. The Plan denied 
your request. The Plan says procedure code 99070 is considered bundled and not separately payable.  
 
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 99070 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99070 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99070 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99070 billed for date of service October 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service September 
21, 2023.  
 
You asked the Plan to pay for procedure code 86077. You say that the service is supported by the records. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service September 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the injections provided from March 15, 
2023, to April 12, 2023. 
 
You asked the Plan to waive the coinsurance for the injections. You say that you are requesting reconsideration 
of the coinsurance applied to the claim. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay $426.56, which is 20% coinsurance of the allowed amount for the injection 
provided on March 15, 2023 ($2,132.79 allowed amount x 20% = $426.56). You have also been asked to pay $423.99, which is 20% coinsurance of the allowed amount for the injection provided on April 12, 2023 
($2,119.94 allowed amount x 20% = $423.99). These 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 injections provided from 
March 15, 2023, to April 12, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on May 12, 2023. 
 
You asked the Plan to pay for the office visit (99214). You say that the service was medically necessary. 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 (99214) 
provided on May 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4239 provided on August 30, 2023. 
 
You asked the Plan to pay for procedure code A4239. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services exceed the benefit limit. 
 
The Plan must follow Medicare rules. The rules say that only one (1) month, thirty (30) days of the supply 
allowance may be billed at a time. 
 
We looked at the file and Medicare rules. The file shows that the Plan paid for a one month supply of code 
A4239 prior to the date of service at issue and additional units cannot be approved. 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 A4239 provided on August 30, 2023.