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

 
We decided that the Plan does not have to pay for the office visit (99215) and smoking and tobacco use 
cessation counseling visit (99406) provided on July 19, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit (99215) and smoking and tobacco 
use cessation counseling visit (99406) provided on July 19, 2023, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for rheumatology injections provided on June 
23, 2023. 
 
You asked the Plan to waive the coinsurance for rheumatology injections. You say that you feel you should not 
have to pay this copayment. You were unaware of the coinsurance. 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 drugs. 
 
You have been asked to pay 20% coinsurance for rheumatology injections. This item/service falls within the 
Medicare Part B 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. The total you owe is $299.67. Therefore, we decided that the Plan does not have to waive 
the coinsurance for rheumatology injections provided on June 23, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for practitioner services provided on August 31, 2023, billed with 
procedure code 99152-59-GC. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that documentation does not support the billed 
code. 
 
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 
99152-59-GC is a column II code to column I code 45385; however, 99152-59-GC was billed with a modifier. 
 
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 practitioner services provided. Our reviewer says that 
documentation does support the billed code. Our reviewer found that the medical records do support the use of 
the moderate sedation 99152 being billed with the colonoscopy code of 45385. The records indicate that the 
sedation was given and the time the sedation was provided. Use of the modifier 59 is appropriate as it was done 
in addition to the colonoscopy procedure. 
 
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 practitioner services provided have been met. Therefore, we decided that the 
Plan has to pay for practitioner services provided on August 31, 2023, billed with procedure code 99152-59-
GC.  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204) provided on June 19, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the physician service. You say that the clinic was not aware that prior 
authorization was required. The Plan denied your request. The Plan says services performed by an out-of-
network provider are 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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit (99204) provided on June 19, 2023, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on January 
24, 2023. 
 
You asked the Plan to pay for the periodontal maintenance (D4910). You say that you have been to this same 
office for many years and always had three periodontal cleanings per year. The Plan denied your request. The 
Plan says the service is 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, the periodontal maintenance (D4910) 
is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
periodontal maintenance (D4910) provided on January 24, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says admission to an IRF is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is walking 75 feet with a walker with no touch assistance and is able to 
transfer with light touch assistance. The enrollee does not require the intensive, interdisciplinary care offered 
by an IRF and their medical issues are largely managed.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 standard power operated vehicle (POV) 
(K0806). 
 
You asked the Plan to pre-approve a Group 2 standard POV. You say that you recently had shoulder surgery, 
and you have arthritis in your hands that would hinder you using a wheelchair. The Plan denied your request. 
The Plan says your mobility limitation does not significantly interfere with your ability to perform activities of 
daily living within your home. 
 
The Plan must follow Medicare rules. Medicare rules say that Group 2 POVs (such as code K0806) have added 
capabilities that are not needed for use in the home, and will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Group 2 standard POV have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Group 2 standard power operated vehicle (POV) (K0806).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rituxan. 
 You asked the Plan to pre-approve the drug. You say that Rituxan is medically necessary to treat the enrollee's 
chronic lymphocytic leukemia. The Plan denied your request. The Plan says that the 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 the drug. Our reviewer says that 
Rituxan is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the 
Plans required drugs Ruxience or Riabni. Also, there is no indication that the Plans required drugs would 
likely be less effective or would likely have adverse effects for the enrollee.  
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Rituxan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor (99212) on June 
30, 2023. 
 
You asked the Plan to pay for the chiropractic services. You say that there are no in-network providers for 
eighty miles, and you do not drive. Without chiropractic services you are not able to walk and are a fall risk. 
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 the office visit provided by a chiropractor (99212) on June 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat transforaminal lumbar epidural steroid injections. 
 
You asked the Plan to pre-approve the epidural steroid injections. You say that the request is medically 
necessary. The Plan denied your request. The Plan says the medical necessity criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that repeat epidural steroid injections require 50% or more 
pain relief for three months.  
 
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 epidural steroid injections. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the LCD criteria 
requires 50% or more pain relief for three months. This was not achieved and therefore, the request is deemed 
not medically reasonable and 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 epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve repeat transforaminal lumbar epidural steroid injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric services. 
 
You asked the Plan to pre-approve inpatient psychiatric services. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says the request for continued 
stay at the psychiatric inpatient hospitalization level of care is not approved. 
 
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 inpatient psychiatric services. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the records were supervised and evaluated by a physician. Based upon 
review the records provided for the admission of this enrollee does not meet the criteria for December 19, 2023 
forward as this enrollee was not shown to be a danger to themselves or others, delusions, auditory or visual hallucinations noted. The enrollee was cooperative/compliant with treatment while not showing any threats the 
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 services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided on October 4, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the physician service. You say that the service was medically necessary. The 
Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the office visit (99213) provided on October 4, 2023, by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an adjustable bed. 
 
You asked the Plan to pre-approve the requested bed. You say that the enrollee is in a lot of pain. The Plan 
denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The requested queen size adjustable bed 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 an adjustable bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services (D3911). 
 
You asked the Plan to pre-approve the dental service (D3911). You say that you would like to request 
reconsideration of the denied claim and that the services requested are medically necessary. The Plan denied 
your request. The Plan says the service is 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 Plan's 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 the 
dental services (D3911).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020), spherocylinder, bifocal lens (V2203), 
photochromatic tint (V2744), anti-reflective coating (V2750), and polycarbonate or equal lens (V2784) 
purchased on September 14, 2023. 
 
You asked the Plan to pay for the eyewear. You say that you were not advised by the provider's staff that your 
benefits were not available. You also say that you cannot afford to pay this. The Plan denied your request. The 
Plan says this eyewear purchase exceeds the maximum benefit per period. 
 
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 covers these services when once every two years. 
 
 
 
 We looked at the file and the Plan's rules. The record shows that the Plan issued payment for another set of 
eyewear purchased on date of service August 26, 2022, and your eyewear benefit has been exhausted. Based on 
this information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we 
decided that the Plan does not have to pay for the frames (V2020), spherocylinder, bifocal lens (V2203), 
photochromatic tint (V2744), anti-reflective coating (V2750), and polycarbonate or equal lens (V2784) 
purchased on September 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on May 22, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the physician service. You say that no records were provided per confidentiality 
guidelines. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit (99214) provided on May 22, 2023, 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan 
denied your request. The Plan says further therapy can be provided safely in other settings, such as a skilled 
nursing facility, home with home health services or home with outpatient therapy.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found documentation shows that the enrollee is able to walk 10 feet with a gait belt and a 
walker, that they are leaning while walking, and that their bed to chair transfer required moderate assist with 
50% patient effort. Based on the enrollee's condition, it does not appear that they will be able to participate in 
three hours per day five days per week of 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
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 LTACH services. You say that the enrollee can safely be admitted to an 
LTACH for management of ongoing clinical needs and care. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate inpatient acute care and does not require transfer to an LTACH. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the acute hospital can provide for all the enrollees present inpatient care needs and 
the enrollee is receiving an appropriate level of care in the present setting. The provided records do not explain 
what care services will be provided in the LTACH that are not currently available. The records do not support the need to transfer from one acute hospital to another. Continued care in the short-term acute hospital is 
appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation 
facility, a sub-acute rehabilitation facility, or a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on August 15, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $2,250 annual maximum 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 $2,250 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for dental services provided on August 15, 2023.