Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic endoscopy and colonoscopy 
provided on May 12, 2023. 
 
You asked the Plan to waive the copayment for the diagnostic endoscopy and colonoscopy. You say that you 
were told this would be fully covered as a preventative procedure. 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 $350 
copayment for in-network outpatient surgery provided at an outpatient hospital. 
 
You have been asked to pay a $350 copayment for the diagnostic endoscopy and colonoscopy. This 
item/service falls within the in-network outpatient surgery provided at an outpatient hospital 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 records show this 
services were diagnostic, and the outpatient surgery copayment was correctly applied. Therefore, we decided 
that the Plan does not have to waive the copayment for the diagnostic endoscopy and colonoscopy provided on 
May 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic care and acupuncture provided by an OON 
chiropractor on May 24, 2023.  
 
You asked the Plan to pay for the chiropractic care and acupuncture. You say that you are appealing the claim 
payment denial. The Plan denied your request. The Plan says the services are not authorized because the 
provider is out-of-network. The service could have been provided by an in-network provider. 
 
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 chiropractic care and acupuncture provided by an 
OON chiropractor on May 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for  a cortisone injection provided on 
November 21, 2022. 
 
You asked the Plan to waive the deductible for  a cortisone injection. You say that this was just an injection so 
you shouldn't have a charge. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1000 deductible which applies to cortisone injections as it is 
considered a surgical procedure.  
 
 
 
 
 The item or service you asked the Plan to waive the deductible for falls within the Outpatient Diagnostic Tests 
and Procedures benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract 
that there is a $1000 deductible which applies to surgical procedures. This cost sharing is a contractual 
obligation that had not been met at the time a cortisone injection was received on November 21, 2022. 
Therefore, we decided that the Plan does not have to waive the deductible for  a cortisone injection provided on 
November 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 10, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that this is supported in the records. 
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 subsequent nursing 
facility care provided on July 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper overdenture (D5863), the surgical 
placement of implant body (D6010), and a custom abutment (D6057) for tooth #3, #6, #11, and #14. 
 
You asked the Plan to pre-approve the dental services. You say that the implants are needed to support the 
denture. The Plan denied your request. The Plan says the denial of authorization for the overdenture is correct 
because there is no documentation showing previous denture is no longer good and the x-rays do not show that 
you have implants in your mouth to hold the denture in place. Also, dental implants and all associated services 
are not covered by the Plan. 
  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. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says 
that the complete upper overdenture is not medically necessary. Our physician reviewer found that an 
overdenture is supported by natural teeth or implants. According to the documentation implants are beyond the 
scope of the plan. Before an overdenture is approved, there must be verification that implants have been placed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the complete upper overdenture have not been met. The surgical placement of 
implant body and a custom abutment are not covered under the Plans dental benefit. Therefore, we decided 
that the Plan does not have to pre-approve a complete upper overdenture (D5863), the surgical placement of 
implant body (D6010), and a custom abutment (D6057) for tooth #3, #6, #11, and #14.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (22514). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the 
requested service.  
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebroplasty (PVP) or percutaneous 
kyphoplasty (PKP) is covered in patients with both of the indicated criteria.  
 
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 this service. Our reviewer says that the 
enrollee does not meet criteria for coverage of the requested service. Our physician reviewer found that there is 
no trial of bracing for fracture care indicated in the record. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous vertebral augmentation (22514).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services (99222) provided on April 14, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the billed code is 
for inpatient services with an outpatient place of service. 
 
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 inpatient or observation care, per day, for the evaluation and management of a 
patient, which requires a medically appropriate history and/or examination and moderate level of medical 
decision making. When using total time on the date of the encounter for code selection, 55 minutes must be met 
or exceeded". 
 
We find that CPT code 99222 is supported in the medical record. Specifically, the billed code can be used for 
inpatient or observation care, and therefore is appropriate to use with an outpatient place of service. Based on 
this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we 
decided that the Plan has to pay for the services (99222) provided on April 14, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 25609 and 29125. We 
decided that the Plan does not have to pay for the services described by procedure code(s) 76000.  
 
You asked the Plan to pay for codes 76000, 25609, and 29125 performed on date of service March 20, 2023. 
You say that codes 76000, 25609, and 29125 should be paid as billed because they are supported in the 
documentation. The Plan says that code 76000 is denied because it was billed without the required modifier -
26. Codes 25609 and 29125 were handled as an original decision reopen for New and Material Evidence, 
therefore no appeal decision was made. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 25609 and 29125.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 25609 and 29125.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
76000. 
 
The Plan follows Medicare rules. Medicare rules say that carriers may not pay for the technical component 
(TC) of radiology services furnished to hospital patients. 
 
We looked at the file and Medicare rules. We confirmed that 76000 is a radiology service which has a separate 
TC and PC, and the enrollee received this service at an on-campus outpatient hospital. We confirmed that in 
this case, 76000 was not billed with modifier -26. According to Medicare rules, modifier -26 is required as the 
TC of a radiology service which has both a TC and PC cannot be paid to the physician when the enrollee 
receives services while at a hospital. Based on this information, we decided that Medicare rules for coverage of 
the services described by procedure code(s) 76000 have not been met. Therefore, we decided that the Plan does 
not have to pay for the services described by procedure code(s) 76000. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation and cone beam computed 
tomography (CT) scan (D0367, D0140) provided on July 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the limited oral evaluations has 
already been exhausted. This benefit does not include cone beam CT scans. 
 
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 limited oral evaluation was exhausted on date of service June 20, 2023 (D0140) 
Additionally, this benefit does not include cone beam CT scans. Therefore, we decided that the Plan does not 
have to pay for a limited oral evaluation and cone beam computed tomography (CT) scan (D0367, D0140) 
provided on July 18, 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 LTACH level of care is the only option 
for a safe discharge due to the need for frequent nursing care, daily physician management, telemetry, frequent 
labs, daily chest x-rays, nutritional management, along with physical and occupational therapies in order to 
return home successfully. The Plan denied your request. The Plan says it is not safe for the enrollee to leave the 
hospital at this time because the most recent progress notes indicate the enrollee's recently gotten worse. 
 
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 the enrollee is receiving appropriate care in current acute care setting as provided by the Plan. Documentation does not support that LTACH services are medically appropriate at this time. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service December 
30, 2022.  You asked the Plan to pay for procedure code 88341. You say that the documentation supports the additional 
testing. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed 14 units of this 
code, exceeding the MUE. The medical record does not show that the excess units were medically necessary. 
The records do not document a specific reason why additional units were needed in this case. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service December 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network urology telehealth visit 
provided on October 28, 2022. 
 
You asked the Plan to waive the copayment for an in-network urology telehealth visit. You say that you are 
dissatisfied that you have to pay for a phone call. 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 $50 
copayment for provider/physician services including doctors office visits. 
 
You have been asked to pay a $50 copayment for an in-network urology telehealth visit. This item/service falls 
within the provider/physician 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. Therefore, we decided that the Plan 
does not have to waive the copayment for an in-network urology telehealth visit provided on October 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 1, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the laboratory services. You say that the tests provide valuable information for 
providers. The Plan denied your request. The Plan says the services were 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 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 laboratory services provided on March 1, 
2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and diagnostic injection provided on January 
10, 2023. 
 
You asked the Plan to pay for an office visit and diagnostic injection. You say that this was medically 
necessary and should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit and 
diagnostic injection provided on January 10, 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 admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee's condition does not meet all of the 
requirements for inpatient rehabilitation admission. The Plan says are can 
continue to be provided in the current inpatient hospital. 
 
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 the enrollee is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate at this time.  
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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an Ottobock Triton Prosthetic foot (L5981 + L5986). 
 
You asked the Plan to pre-approve an Ottobock Triton Prosthetic foot. You say that the item is medically 
necessary. The Plan denied your request. The Plan says that the item exceeds the members needs. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of foot. This 
information must be retained in the treating practitioner's or prosthetist's files. 
 
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 Ottobock Triton Prosthetic foot. Our 
reviewer says that the item is medically necessary. Our physician reviewer found the enrollee is a K3 
ambulator and the medical records demonstrate the need for this item. 
 
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 Ottobock Triton Prosthetic foot have been met. Therefore, we decided that 
the Plan has to pre-approve an Ottobock Triton Prosthetic foot (L5981 + L5986).  
 
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.