Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for drug injection provided on July 14, 2022. We also 
decided that the Plan does not have to waive the copayment for the endoscope procedure provided on July 14, 
2022.  
 You asked the Plan to waive the cost share for the endoscope procedure and drug injection. You say that you 
have only had to pay an office visit copayment for this service in the past. The Plan denied your request. The 
Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to waive the coinsurance for drug injection provided on July 14, 2022.  
 
You have been asked to pay 20% coinsurance for the drug injection. According to Medicare, the injection 
(J3590) is considered a packaged code and is not separately payable. This code is also excluded from the 
physicians free schedule. Therefore, we decided that the Plan has to waive the coinsurance for drug injection.  
 
We also decided that the Plan does not have to waive the copayment for the endoscope procedure 
provided on July 14, 2022. 
 
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 $350 
copayment for outpatient surgery provided at an outpatient hospital. 
 
You have been asked to pay $286.95, which is less than the standard $350 copayment for the endoscope 
procedure. This item/service falls within the outpatient surgery 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 cost share for the endoscope procedure provided on July 14, 2022. 
 
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: Favorable

 
We decided that the Plan has to pre-approve the paravertebral facet joint injections. 
 
You asked the Plan to pre-approve the injections. You say that the enrollee struggles with chronic debilitating 
back pain which has made their daily living very difficult. The Plan denied your request. The Plan says that the 
paravertebral facet joint injections are not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 the injections. Our reviewer says that 
the enrollee does meet the coverage criteria. Our physician reviewer found that the enrollee has chronic low 
back pain with both axial and radicular components. The enrollee has had an epidural steroid injection without 
relief. The enrollee also had a sacroiliac joint injection, and a RFA of the bilateral L5-S1 in 2019 and 2021. 
These injections are a repeat RFA after a 2-year period of pain relief, which meets the criteria for medial 
branch blocks. 
 
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 injections have been met. Therefore, we decided that the Plan has to pre-
approve the paravertebral facet joint injections.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on July 4, 2022, to 
July 7, 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 
physician diagnosed and treated the enrollee appropriately. The Plan denied your request. The Plan says the 
documentation does not support the diagnosis. 
 
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 with diagnosis code I50.21, defined as congestive heart failure. 
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 physician reviewer found that the enrollee presented with chest pain. Nitroglycerin was 
given. The workup revealed a non-ST-elevation myocardial infarction (NSTEMI) and the enrollee underwent 
cardiac catheterization procedure. The examination revealed no wheezing or rales or edema in legs. Although 
the enrollees echocardiogram revealed some degree of heart failure, there was insufficient clinical signs of 
congestive heart failure requiring intervention. The echocardiogram results were a result of the primary 
diagnosis of NSTEMI. Therefore, the documentation does not support the code, I50.21 - congestive heart 
failure for this admission.   
 
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 the inpatient hospital services provided on July 4, 2022, to July 7, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on July 18, 2022, to 
July 26, 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. The Plan denied your 
request. The Plan says the billed DRG is not supported. 
 
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 diagnosis code R65.21. 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 the use of diagnosis code R65.21 is not supported by the records provided. Our physician 
reviewer found that although the diagnosis of septic shock is documented in the history and physical, there was 
no clinical or laboratory evidence of sepsis. The documentation does not support diagnosis code R65.21.  
 
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 the inpatient hospital services provided on July 18, 2022, to July 26, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an osseous surgery (D4260), a bone replacement graft for 
ridge preservation (D7953), a bone replacement graft (D4263), a guided tissue regeneration (D4266) and 
extractions (D7210), provided on October 27, 2022, to November 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services should be covered. The Plan 
denied your request. The Plan says these services were processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for D7210 was exhausted on date of service October 27, 2022, with the approved 
extractions for teeth #3 and #14. This benefit does not include D4260, D7953, D4263, or D4266. Therefore, we decided that the Plan does not have to pay for an osseous surgery (D4260), a bone replacement graft for ridge 
preservation (D7953), a bone replacement graft (D4263), a guided tissue regeneration (D4266) and extractions 
(D7210), provided on October 27, 2022, to November 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric services beyond July 5, 
2023. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the continued inpatient psychiatric services are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 these services. Our reviewer says that 
the continued inpatient psychiatric services are not medically necessary. Our physician reviewer found the 
enrollee was admitted to the hospital on January 1, 2023 with bipolar-type schizoaffective disorder. Based on 
the submitted records, it was not expected that he would improve in a reasonable period of time beyond the 
dates in question, as he was not showing any dangerousness to self or others, auditory or visual hallucinations, 
and had no aggressive behaviors or acute threats of safety. He did not have suicidal or homicidal thoughts. It 
does not appear that active treatment was taking place beyond the dates in question. The records do not support 
that continued inpatient psychiatric services beyond July 5, 2023 are 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued inpatient psychiatric services beyond July 5, 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 appeal and have 
provided a clinical summary and clinical documentation to support this request. The Plan denied your request. 
The Plan says criteria for admission to the acute IRF setting have not been met.  
 
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 nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service December 20, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. The Plan denied your request. The Plan says code 99153 
is not payable in the facility setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.   
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service December 20, 2022, 
billed with code 99153.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Spiriva Respimat. 
 
You asked the Plan to pre-approve the medication. The Plan denied your request. The Plan says the medication 
is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Spiriva Respimat.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on December 20, 2022. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on December 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service January 11, 2023. 
 
You asked the Plan to pay for code 99285. You say that the medical record documentation meets the applicable 
requirements for code 99285. The Plan denied your request. The Plan says code 99285 was not supported by 
the medical record. The claim has been down-coded to 99283 to reflect the services provided. 
 
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect 
the services provided.   
 
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the 
evaluation and management of a patient which requires three components (taking into account the urgency of 
the clinical condition or the patient's mental status): 
 
1. a comprehensive history; 2. a comprehensive examination; and 
3. medical decision making of high complexity. 
 
In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate 
significant threat to life or physiologic function.  
 
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 code 99285 Our reviewer says that code 
99285 was not supported by the medical record. Our reviewer found the patient is an 81-year-old male who 
presented to the emergency room on January 11, 2023, after a fall hitting his head 2 days prior. The provided 
documentation from that date describes the patient with dizziness, hip pain, headache without other symptoms 
or history of loss of consciousness. The documentation was an expanded problem focused history. The 
examination revealed laceration and hematoma on the head. The documentation showed an expanded problem 
focused examination. Imaging was all negative for acute findings. He was treated with staples and basic wound 
care. His vitals were stable. He was discharged home. The documentation did not support a comprehensive 
history or examination, nor did it support medical decision-making of high complexity. Therefore, the code, 
99285 is not sufficiently supported for this encounter.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285 billed for date of service January 11, 2023.
Appeal type: Step-Therapy
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 is contraindicated for bisphosphonate 
therapy. You say that Prolia is the most effective medication for the enrollee. You also say that the enrollee has 
tried and failed Actonel. The Plan denied your request. The Plan says the enrollee has not tried and failed the 
preferred drugs, an oral bisphosphonate drug (such as alendronate, risedronate, and ibandronate) or zoledronic 
acid. 
 
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 
that the enrollee has tried and failed one of the preferred drugs, an oral bisphosphonate drug (such as 
alendronate, risedronate, and ibandronate) or zoledronic acid. The reviewer found that the documentation does 
not support that an oral bisphosphonate drug (such as alendronate, risedronate, and ibandronate) or zoledronic 
acid would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the photochromatic tint lenses (V2744) provided on March 
16, 2023. 
 
You asked the Plan to pay for the photochromatic tint lenses. You say that you needed the enhancement as you 
cannot see in the sun. The Plan denied your request. The Plan says this service is not a covered benefit. The 
Plan also says that the records show that this enhanced service was made available to you at a rate of $75.00, 
which the office has confirmed you have already met this financial obligation. 
 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 standard contact lenses, eyeglasses, single vision or lined multi-focal lens and frame. 
 
We looked at the file and the Plan's rules. The contract specifically states that enhancements, including 
photochromic lenses, are not covered through the allowance but may be purchased by you at an additional cost. 
Based on this information, we decided that the Plan's rules for coverage of the photochromatic tint lenses have 
not been met. Therefore, we decided that the Plan does not have to pay for the photochromatic tint lenses 
(V2744) provided on March 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care visit provided on January 
16, 2023. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that you received poor care from 
the provider. 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 $45 
copayment for urgently needed services. 
 
You have been asked to pay a $45 copayment for the urgent care visit. This item/service falls within the 
urgently needed services 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 the urgent 
care visit provided on January 16, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that  The Plan denied your request. The Plan 
says an LTACH admission is not medically necessary.  
 
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 the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. The health plan has approved ongoing care in 
the current acute care setting. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.