Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane (J7318). 
 You asked the Plan to pre-approve Durolane. You say that the request is medically necessary. The Plan denied 
your request. The Plan says step therapy requirements have not been met. 
 
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 Durolane. Our reviewer says that the 
criteria for coverage of Durolane have not been met. Our physician reviewer found the Plan requires that 
preferred viscosupplemental treatment, such as Monovisc, Orthovisc, Synvisc, or Synvisc-One be trialed first. 
The documentation does not outline contraindications or reasons these medications were not considered or that 
the Plan's additional required drugs would likely be less effective and/or likely have adverse effects for you. 
Without the support of the documentation, Durolane is not approved as step 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 Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane (J7318).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation and extraction (D0140, D7210) 
provided on July 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the limited oral evaluation has 
already been exhausted. Additionally, extractions are not 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 Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 5, 2023 (D0140). 
Additionally, extractions are not a covered benefit. Therefore, we decided that the Plan does not have to pay for 
a limited oral evaluation and extraction (D0140, D7210) provided on July 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services (D2950) provided on June 1, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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. 
 
 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 pay for core 
buildup services (D2950) provided on June 1, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
April 29, 2023, to May 20, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that this would be a 
financial burden for you. 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 $380 
copayment for inpatient hospital care.  
You have been asked to pay a $380 copayment for the 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. You have been asked to pay a total of $1,900 for the inpatient hospital stay ($380 
copayment per day x 5 days = $1,900). You have not been charged for the day you were discharged. Therefore, 
we decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on April 
29, 2023, to May 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated resin crown (D2932) provided on July 20, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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. 
 
 
  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 pay for a 
prefabricated resin crown (D2932) provided on July 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits provided on February 22, 2023, and April 
11, 2023. 
 
You asked the Plan to pay for the office visits. You say that you were unaware that the provider was not 
participating with Medicare. The Plan denied your request. The Plan says the provider is not enrolled in the 
Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the office visits provided on February 
22, 2023, and April 11, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each emergency room (ER) visit provided 
on March 31, 2023, to April 16, 2023. 
 
You asked the Plan to waive the copayment for each emergency room (ER) visit. You say that you do not agree 
with the cost share applied because you received urgent care services, not emergency care. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for each 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. You have been asked to pay $270 for emergency care services ($90 per visit x 3 visits = 
$270). Therefore, we decided that the Plan does not have to waive the copayment for each emergency room 
(ER) visit provided on March 31, 2023, to April 16, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on 
February 02, 2023, to February 06, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $345 
copayment for inpatient hospital care. 
 
You have been asked to pay a $345 copayment for inpatient hospital care. 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. The total amount you owe is $1,380 ($345 x 4 days = $1,380). Therefore, we decided that 
the Plan does not have to waive the copayment for inpatient hospital care provided on February 02, 2023, to 
February 06, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network spine procedure at a non-
preferred facility provided on May 19, 2023. 
 
You asked the Plan to waive the copayment for an in-network spine procedure at a non-preferred facility. You 
say that this was a minor surgery and should not have been so expensive. 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 $440 
copayment for outpatient hospital observation. 
 
You have been asked to pay a $440 copayment for an in-network spine procedure at a non-preferred facility. 
This item/service falls within the outpatient hospital observation 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 spine procedure at a non-preferred facility provided on May 19, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 19, 2022. 
 
You asked the Plan to pay for the lab services. You say that this claim was billed correctly. The Plan denied 
your request. The Plan says you billed these lab services with the wrong POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill the appropriate POS code for 
services.  POS code 21 indicates that the services were performed in an inpatient hospital setting. POS code 22 
indicates that the services were performed in an outpatient hospital setting. In this case, you billed the claim for 
these services with POS code 22.  However, the documentation shows that the patient was in an inpatient status 
on the date of service at issue. As a result, POS code 21 should have been used on the claim instead. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services provided on December 19, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an office or other outpatient visit (99213) on June 8, 2023. 
 
You asked the Plan to pay for an office visit. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says that rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The case record supports that you submitted a rate letter prior to the Plan's initial 
denial. The Plan does not make any indication that the submitted letter is invalid. It is the Plan's responsibility 
to support its denial with evidence. In this case, the Plan's denial is not supported by the case record, so we 
must find in your favor. Therefore, we decided that the Plan has to pay for an office or other outpatient visit 
(99213) on June 8, 2023.  
 
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: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 99291 billed on June 30, 2023. We decided that the Plan does not have 
to pay for 99291 billed on June 27, 2023, through June 29, 2023, and 99291 billed on July 1, 2023.  
 
You asked the Plan to pay for the evaluation and management services coded as 99291 billed on dates of 
service June 27, 2023, through July 1, 2023. You say that the evaluation and management services billed on 
June 27, 2023, through July 1, 2023, should be paid as billed because they are supported in the documentation. The Plan says that the evaluation and management services are denied because they are not supported in the 
documentation. 
 
We decided that the Plan has to pay for 99291 billed on June 30, 2023.  
 
The Plan follows 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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 billed on date of service June 30, 2023, is supported in the medical record. 
Specifically, the time spent on the encounter is documented as 35 minutes. There are no other services reported 
on the same date of service by the same provider, therefore, it can be presumed that the 35 documented minutes 
were spent on critical care services. Based on this information, we decided that Medicare rules for coverage of 
99291 billed on June 30, 2023, have been met. Therefore, we decided that the Plan has to pay for 99291 billed 
on June 30, 2023. 
 
We also decided that the Plan does not have to pay for 99291 billed on June 27, 2023, through June 29, 
2023, and 99291 billed on July 1, 2023. 
 
The Plan follows Medicare rules. Medicare rules say that that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
We find that CPT code 99291 billed on dates of service June 27, 2023, through June 29, 2023, as well as 99291 
billed on July 1, 2023, are not supported in the medical record. Specifically, there is no documentation of time 
spent performing critical care services, as is required per the code definition of 99291. Based on this 
information, we decided that Medicare rules for coverage of 99291 billed on June 27, 2023, through June 29, 
2023, and July 1, 2023, have not been met. Therefore, we decided that the Plan does not have to pay for 99291 
billed on June 27, 2023, through June 29, 2023, and 99291 billed on July 1, 2023. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76140 billed for date of service April 29, 
2023. 
 
You asked the Plan to pay for procedure code 76140. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 76140 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code 76140 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 76140 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 76140 billed for date of service April 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on May 19, 2023. 
 
You asked the Plan to pay for wound care supplies. You say that the supplies should be covered. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for wound care supplies 
provided on May 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walking boot provided on July 18, 2023. 
 
You asked the Plan to pay for the walking boot. You say that you are requesting retro authorization. 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 walking boot 
provided on July 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit on May 02, 2023.  
 
You asked the Plan to waive the deductible for an office visit. You say that you have always paid a $20 copay 
but this visit went toward the deductible. You believe that you should owe $20 not the $95.48 indicated. 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 $400 deductible which applies to physician/practitioner services, 
including doctors office visits.  
 
The item or service you asked the Plan to waive the deductible for falls within the physician/practitioner 
services, including doctors office visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $400 deductible which applies to physician/practitioner services, 
including doctors office visits. This cost sharing is a contractual obligation that had not been met at the time an 
office visit was received on May 2, 2023. Therefore, we decided that the Plan does not have to waive the 
deductible for an office visit on May 02, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation, panoramic 
radiographic image, complete maxillary denture, and mandibular partial denture (D0330, D0150, D5110, 
D5214) provided on October 6, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. 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 October 6, 2022. Therefore, we decided that the Plan does not have to pay more for a comprehensive oral evaluation, panoramic 
radiographic image, complete maxillary denture, and mandibular partial denture (D0330, D0150, D5110, 
D5214) provided on October 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a bone replacement graft and the collection and 
application of autologous blood concentrate product (D7953, D7921) provided on April 25, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. 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 April 25, 2023. 
Therefore, we decided that the Plan does not have to pay more for a bone replacement graft and the collection 
and application of autologous blood concentrate product (D7953, D7921) provided on April 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation provided on August 16, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 28, 2018. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation provided on 
August 16, 2023.