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

 
We decided that the Plan does not have to pay more for dental root amputation (D3450) provided on December 
8, 2022. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing amount 
when your services are received from an out-of-network provider. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 more for dental root amputation (D3450) provided on 
December 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty over-bed table. 
 
You asked the Plan to pre-approve a heavy-duty over-bed table. You say that this table is medically necessary. 
The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
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 heavy-duty over-bed table.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on 
January 11, 2023. 
 
You asked the Plan to pay for the dental service. You say that your previous dentist closed for good, and you 
did not know there was a difference in the x-rays. 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 the date of service of September 14, 
2020. Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) 
provided on January 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on December 16, 2022. 
 
You asked the Plan to pay for the evaluation and management service. You say that the enrollee's plan has paid 
for services from this provider previously. You also say that this should be covered. The Plan denied your request. The Plan says without medical records it cannot be determined that the services in this case were 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the evaluation and management 
service have been met. Specifically, there were no medical records provided to support that the service in this 
case was medically necessary. Therefore, we decided that the Plan does not have to pay for the office visit 
provided on December 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64447 billed for date of service November 2, 
2022. 
 You asked the Plan to pay for procedure code 64447. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 64447 is bundled into payment for code 01402. 
 
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 64447 
is a column II code to column I code 01402. 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 64447 billed for date of service November 2, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20705 billed for December 13, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 20705 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 20705 is removal of drug-delivery device(s), intra-
articular (List separately in addition to code for primary procedure). 
 
We find that CPT code 20705 is not supported in the medical record. Specifically, this is an add-on code that 
was not billed with a required primary procedure code. 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 20705 billed for December 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 90837 billed for date of service September 
26, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the provider is not eligible to participate 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 procedure code 90837 billed for date of 
service September 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service June 20, 2022. 
 
You asked the Plan to pay for the billed services. You say that the testing was deemed medically necessary. 
The Plan denied your request. The Plan says the test has not been proven to alter treatment outcomes. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. The medical records provided do not show that the testing was 
ordered as part of a symptomatic medical problem. Based on this information, we decided that there is 
insufficient information in the record to determine if Medicare rules for coverage have been met. Therefore, we 
decided that the Plan does not have to pay for the lab testing billed for date of service June 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heart catheterization. 
 
You asked the Plan to pre-approve a heart catheterization. You say that a heart catheterization is medically 
necessary. The Plan denied your request. The Plan says the requested heart catheterization is 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 heart catheterization. Our reviewer 
says that the requested heart catheterization is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the enrollee has a history of shortness of breath on exertion, without chest 
pain. Documentation does not show evidence of an uninterpretable electrocardiogram or inability to 
exercise. Guidelines do not support a need for cardiac catheterization in this setting. As a result, at this time cardiac catheterization would not be considered medically appropriate and necessary in this enrollees clinical 
management. 
 
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 heart catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a heart catheterization.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the enrollee has declined oral medications. You also 
say that the enrollee will benefit from Prolia injection. The Plan denied your request. The Plan says the enrollee 
has not trialed zoledronic acid for at least 12 months. 
 
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 Prolia. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
the enrollee has tried and failed the preferred drug. The reviewer also found that the medical records provided 
and the Medicare-approved major drug compendia there is no indication that the plan's required drug would 
likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that the 
step therapy 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Spravato. 
 
You asked the Plan to pre-approve Spravato. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Spravato. Our reviewer says that 
Spravato is not medically necessary. Our physician reviewer found provided medical records do not document 
that the patient's history of controlled substance prescriptions has been checked using the state prescription 
drug monitoring program. As stated in the Medicare approved compendia, monitoring for risk for abuse or 
misuse of Spravato is recommended prior to starting therapy in all patients. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Spravato have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Spravato.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the repair of knee joint (27447) evaluation 
of physical therapy (PT), typically 30 minutes (97162) and pay for the self-administered drugs (A9270), 
provided on October 25, 2022. 
 
You asked the Plan to waive the cost share for the repair of knee joint, PT, and pay for the self-administered 
drugs. You say that the services should be covered. The Plan denied your request. The Plan says this cost 
sharing was charged correctly and self-administered drugs are not covered by this Plan. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for PT and a 20% coinsurance for surgery or observation room service. Medicare Part B generally 
does not pay for drugs that are usually self-administered by the patients who take them. 
 
You have been asked to pay a $40 copayment for PT and a 20% coinsurance for surgery or observation room 
service for the repair of knee joint and PT. 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 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 waive the cost share for the repair of 
knee joint (27447) evaluation of physical therapy (PT), typically 30 minutes (97162) and pay for the self-
administered drugs (A9270), provided on October 25, 2022.  
 
Benefits for the self-administered drugs 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: 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 enrollee meets the IRF admission criteria, and 
their ongoing rehabilitative needs warrant an IRF level of care to achieve a safe and sustainable discharge. The 
Plan denied your request. The Plan says the requested IRF admission 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 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 benefit from 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 9, 2022, to 
February 12, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says 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 inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code I25.5, described as 
Ischemic cardiomyopathy. 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 pay for the inpatient 
hospital services at the DRG originally billed. Our reviewer says that documentation does not support the billed 
code. Our physician reviewer found that the enrollee presented after a fall. While the enrollee has a history of 
ischemic cardiomyopathy, it appears that the main reason for the admission, and the main focus of treatment, 
was heart failure. As such, the billing of I25.5 as the principal diagnosis is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on February 9, 2022, to February 12, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a below knee replacement socket (L5700). 
 
You asked the Plan to pre-approve a below knee replacement socket. You say that this is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that socket replacements are considered reasonable and 
necessary if there is adequate documentation of functional and/or physiological need. 
 
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 below knee replacement socket. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the documentation 
does not support that there are significant changes in the residual limb, functional need changes, or irreparable 
damage or wear and tear that require a socket replacement. The documentation does not support by the 
objective measurements in the progress notes that there are significant limb volume changes. The enrollee's 
weight appears consistent per documentation. There is no evidence that the enrollee has failed short socks, 
thicker gel liners or padding to the socket.  
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 below knee replacement socket have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a below knee replacement socket (L5700).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99222) provided on November 15, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99222 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) 
requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit". 
 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 services. Our reviewer says that the use of code 99222 is 
not supported by the records provided. Our reviewer found that the physical examination in this case is not 
comprehensive. As such, the billing of CPT code 99222 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (99222) provided on November 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the copayments applied to chiropractic services received 
from January 19, 2022, to December 19, 2022. 
 
You asked the Plan to pay for copayments for covered services. You say that you would like to be reimbursed 
for these copayments under your wallet benefit. The Plan denied your request. The Plan says copayments are not eligible for reimbursement under this benefit; a copayment is your responsibility of the cost for a covered 
service and is not the responsibility of the Plan. 
 
The Plan must follow Medicare rules. 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 $20 copayment for Medicare-covered chiropractic visits. Your Plan also 
provides an additional benefit to cover services which are not covered by Original Medicare. For this benefit, 
the Plans rules apply in this case. The Plans benefit offers a supplemental option for up to $400 
reimbursement per year towards the cost of chiropractic visits for routine care which is not covered by Original 
Medicare. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
reimbursement of copayments for covered services is not a covered benefit. The record shows that the visits at 
issue have been covered by your Plan under your medical benefit and processed so that you owe only a $20 
copayment for each visit. This is to your advantage as you would be responsible for the full cost of each visit if 
these services were not considered medically necessary, and you would only be eligible for up to $400 
reimbursement for the year. Copayments for Medicare-covered services are not eligible for reimbursements 
under this benefit. Therefore, we decided that the Plan does not have to pay for the copayments applied to 
chiropractic services received from January 19, 2022, to December 19, 2022.