Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for periodontal scaling and root planing - four 
or more teeth per quadrant (D4341 x4) provided on February 25, 2023. 
 
You asked the Plan to waive the cost share for the periodontal scaling and root planing, localized delivery of 
antimicrobial agents via a controlled release, gingival irrigation - per quadrant, and drugs or medicaments 
dispensed in the office for home use. You say that you are requesting that the services be covered under your 
medical benefits. 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 enrollees must pay 
50% coinsurance after you pay your $25 innetwork dental deductible coinsurance for each comprehensive 
dental service. The Plan contract also says we pay up to $750 each year for nonMedicare covered preventive 
and comprehensive dental services. 
 
You have been asked to pay a total of $306.50.  
 
 
SERVICE 
ALLOWED 
AMOUNT 
PLAN 
PAID 
ENROLLEE 
RESPONSIBILITY 
NOTES ON CURRENT 
STATUS 
D4341 $186.50 $100.50 $86.00 Deductible & Coinsurance 
D4341 $147.00 $73.50 $73.50 Coinsurance 
D4341 $147.00 $73.50 $73.50 Coinsurance 
D4341 $147.00 $73.50 $73.50 Coinsurance 
D4381 $43.00 $43.00 $0.00 Paid at 100% of allowed 
D4381 $43.00 $43.00 $0.00 Paid at 100% of allowed 
D4381 $43.00 $43.00 $0.00 Paid at 100% of allowed 
D4381 $43.00 $43.00 $0.00 Paid at 100% of allowed 
D4381 $43.00 $43.00 $0.00 Paid at 100% of allowed 
D4381 $43.00 $43.00 $0.00 Paid at 100% of allowed 
D4381 $43.00 $43.00 $0.00 Paid at 100% of allowed 
D4921 $19.00 $19.00 $0.00 Paid at 100% of allowed 
D4921 $19.00 $19.00 $0.00 Paid at 100% of allowed 
D4921 $19.00 $19.00 $0.00 Paid at 100% of allowed 
D4921 $19.00 $19.00 $0.00 Paid at 100% of allowed 
D9630 $26.00 $26.00 $0.00 Paid at 100% of allowed 
D9630 $26.00 $26.00 $0.00 Paid at 100% of allowed 
TOTAL $1056.50 $750.00 $306.50  
 
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. This service falls within 
the comprehensive dental services benefit category. Therefore, we decided that the Plan does not have to waive 
the cost share for periodontal scaling and root planing - four or more teeth per quadrant (D4341 x4) provided 
on February 25, 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 are requesting an expedited reconsideration as 
the enrollee currently meets full IRF criteria. The Plan denied your request. The Plan says the service requested 
is not supported based on the records received.  
 
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 complexity of the enrollee's documented nursing, medical and rehabilitation 
needs would not be expected to require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The clinical documentation shows that the enrollee requires ongoing skilled physical and 
occupational therapy however, it does not show that the enrollee would tolerate or require an intensive 
rehabilitation regimen. 
 
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 an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is the most appropriate discharge 
disposition for the enrollee, and you would like reconsideration based on the records submitted. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an IRF.  
 
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 that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Influx Sparc allograft (20930). 
 
You asked the Plan to pre-approve an Influx Sparc allograft. You say that an Influx Sparc allograft is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says an Influx Sparc allograft is 
experimental/investigational. 
 
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 an Influx Sparc allograft. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that Influx Sparc allograft is experimental in surgery. More information is needed to demonstrate its safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Influx Sparc allograft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Influx Sparc allograft (20930).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transportation services provided on January 11, 2023. 
 
You asked the Plan to pay for the billed services. You say that the service was appropriate. The Plan denied 
your request. The Plan says the service is 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 CPT code. 
 
 We find that ambulance transportation was provided while the enrollee was admitted as an inpatient. Based on 
this information, we decided that Medicare rules for coverage of the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for the transportation services provided on January 
11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 08, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were provided in good faith. 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 lab services provided 
on December 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each specialist office visit provided on 
September 13, 2022, to October 26, 2022. 
 
You asked the Plan to waive the copayment for each specialist office visit. You say that you were told that you 
would not have a 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 $25 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $25 copayment for each specialist office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 $100 ($25 copayment 
x 4 visits = $100). Therefore, we decided that the Plan does not have to waive the copayment for each specialist 
office visit provided on September 13, 2022, to October 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair with multiple 
power options (K0842), combination tilt and recline (E1007), center mount power elevating leg rest/platform 
(E1012), and electronic connection (E2311). 
 
You asked the Plan to pre-approve a group 2 standard power wheelchair with multiple power options, 
combination tilt and recline, center mount power elevating leg rest/platform, and electronic connection. You 
say that you were unable to get your power chair fixed. The Plan denied your request. The Plan says based on 
Medicare guidelines, the group 2 standard wheelchair (K0842) and accessories requested do not meet the 
requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 
 
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 group 2 standard power wheelchair 
with multiple power options, combination tilt and recline, center mount power elevating leg rest/platform, and 
electronic connection. Our reviewer says that a group 2 standard power wheelchair with multiple power options 
is not medically reasonable and necessary for you. Our physician reviewer found you have an amputation of 
your right leg and have used a power wheelchair. You are now requesting a new group 2 power wheelchair. 
Our reviewer found that you are not at high risk for skin breakdown, do not use a catheter, and do not have 
spasticity complicating your positioning. Our physician reviewer also found that you do not require alternative 
means of power drive control. 
 
 
 
 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 group 2 standard power wheelchair with multiple power options, combination 
tilt and recline, center mount power elevating leg rest/platform, and electronic connection have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a group 2 standard power wheelchair with 
multiple power options (K0842), combination tilt and recline (E1007), center mount power elevating leg 
rest/platform (E1012), and electronic connection (E2311).
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 87653. We decided that the Plan does not have to pay 
for procedure code 87481.  
 
You asked the Plan to pay for procedure codes 87481 and 87653 billed for date of service December 12, 2022. 
You say that these services were reported appropriately and are supported in the medical record. The Plan says 
that these services are not supported for separate reporting or payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We decided that the Plan has to pay for procedure code 87653.  
 
In this case, we have confirmed that code 87653 is a column II code to column I code 87801; however, 87653 
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 procedure code 87653. Our reviewer says that code 87653 
with modifier XU is supported. Our reviewer found that according to the guidelines in the CPT codebook for 
code 87801, For each specific organism detection from a primary source, see 87481-87660. Therefore, 87653 is 
supported in the medical record and was reported in accordance with CPT guidelines. 
 
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 code 87653 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 87653.  
 
We also decided that the Plan does not have to pay for procedure code 87481. 
 
In this case, we have confirmed that code 87481 is a column II code to column I code 87801. 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 87481. 
 
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 an office visit provided on May 3, 2022, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this service was not authorized. 
 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 Plan contract says that authorization rules apply for an out-
of-network office visit under the enrollees POS benefit. 
 
The requested 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 an office visit provided on May 3, 2022, by an 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service February 7, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says an incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
 We find that CPT code 99223 was billed with 21, an inpatient place of service code. The enrollees claim 
information shows that the enrollee was in outpatient observation at the time the services were provided. Based 
on this information, we decided that Medicare rules for coverage of the services provided have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99223 billed for date of service 
February 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 24, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that you were unable to see a doctor in-network. The 
Plan denied your request. The Plan says there are providers in your network who are able to take new patients. 
 
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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
 The requested 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 provided on January 24, 2023, by 
an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left heart catheterization. 
 
You asked the Plan to pre-approve left heart catheterization. You say that the enrollee is very sick. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules state that cardiac catheterization may be covered for certain 
indications. 
 
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 left heart catheterization. Our reviewer 
says that the enrollee does not meet criteria for this procedure. Our physician reviewer found an 
echocardiogram in June 2023 showed a normal ejection fraction of 60% to 65%. There is no evidence of an 
uninterpretable electrocardiogram. The records do not support the rationale of this invasive imaging study or 
the need for catheterization in this setting. This would not be considered medically 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 left heart catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve left heart catheterization.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient surgery services provided on February 24, 2023, 
by an out-of-network (OON) provider.  
   
You asked the Plan to pay for outpatient surgery services with an out-of-network provider. You say that you 
were not aware that these services would not be covered. The Plan denied your request. The Plan says services 
with out-of-network providers are not covered except in urgent and emergent situations. There was no reason to 
allow an exception with an out-of-network provider. These services are available in-network. 
 
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 requested 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 outpatient surgery services provided on February 
24, 2023, by an out-of-network (OON) provider.