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

 
We decided that the Plan does not have to pre-approve Spinelogy Optimesh (22853 x2). 
 
You asked the Plan to pre-approve Spinelogy Optimesh. You say that this is medically necessary. The Plan 
denied your request. The Plan says the medical necessity for the denied service has not been established after 
clinical review and per the peer-reviewed medical literature. 
 
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 Spinelogy Optimesh. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Spineolgy Optimesh cage is experimental in spine surgery. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Spinelogy Optimesh have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Spinelogy Optimesh (22853 x2).
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for the services described by procedure code(s) 00630. We decided that the
Plan does not have to pay for the services described by procedure code(s) 99100.

You asked the Plan to pay for practitioner services provided on March 10, 2023, billed with procedure codes
00630-QZ and 99100. You say that the claim is billed correctly and should be paid. The Plan says that code
99100 is an unbundled service.

We decided that the Plan has to pay for the services described by procedure code(s) 00630.

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) 00630.

We also decided that the Plan does not have to pay for the services described by procedure code(s)
99100.

The Plan follows Medicare rules. Medicare rules say that the Physician Fee Schedule Status Indicator B means
that payment for covered services is always bundled into payment for other services not specified. There will
be no payment amounts for these codes and no separate payment is ever made.

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the services described by procedure code(s) 99100 have not been met. Procedure code 99100 has a
status indicator B and is not separately payable. Therefore, we decided that the Plan does not have to pay for
the services described by procedure code(s) 99100.

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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.

You asked the Plan to pre-approve home health services. You say that you would like to request reconsideration of the denied authorization. The Plan denied your request. The Plan says the services are not medically necessary. 

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 home health services. Our reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee does not have documented, ongoing, home health physical therapy needs.  The enrollee is functioning at a level commiserate with a lower 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 home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup, including any pins when required (D2950) 
provided on February 20, 2023. 
 
You asked the Plan to pay for dental services. You say that the denied service should be covered. The Plan 
denied your request. The Plan says this service is not covered under your Plan. 

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Core buildup, including any 
pins when required (D2950) is not covered under the Plan's dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for core 
buildup, including any pins when required (D2950) provided on February 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85007 billed for date of service February 27, 
2023.  
 
You asked the Plan to pay for procedure code 85007. You say that the enrollee has already established care 
with the provider. The Plan denied your request. The Plan says payment for code 85007 is bundled into 
payment for code 85025. 
 
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 85007 is a column II code to column I code 85025 with a modifier 
indicator of 0. The column II code is therefore not payable. 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 85007 
billed for date of service February 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 15, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on November 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission to an LTACH is the safest 
discharge plan, allowing the highest potential for the enrollee's recovery and preventing further deterioration.  
The Plan denied your request. The Plan says the level of care provided in the LTACH setting is more than the 
enrollee's medical conditions need.  
 
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 there is no documentation provided indicating medical necessity for admission to 
an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered 
by the Plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 
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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99152) provided on March 15, 
2023. 
 
You asked the Plan to pay for moderate sedation services (99152). You say that the service was necessary to 
treat the enrollee efficiently. You say that procedure code 99152 is supported in the documentation and should 
be separately reimbursed. The Plan denied your request. The Plan says procedure code 99152 is considered 
inclusive to procedure code 45380 and cannot be separately reimbursed. 
 
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 moderate sedation services provided by the same 
physician or other qualified health care professional performing the diagnostic or therapeutic service that the 
sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the 
patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 
years or older. 
 
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 moderate sedation services (99152). Our reviewer says that 
the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found 
that procedure code 99152 is the incorrect procedure code to report for this service. There is a more appropriate 
code to report for the service provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of moderate sedation services (99152) have not been met. Therefore, we decided 
that the Plan does not have to pay for moderate sedation services (99152) provided on March 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and COVID-19 test provided on March 10, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient services. You say that the enrollee never saw this provider. The 
Plan denied your request. The Plan says prior authorization was not obtained. The Plan also says there was no 
documentation provided to show that these services were urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan 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 and COVID-19 test provided on March 10, 2023, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the cost share for each outpatient clinic visit provided from March 27, 
2023, to April 6, 2023. 
 
You asked the Plan to waive the cost share for each outpatient clinic visit. You say that this amount should be 
sent to Medicaid. The Plan denied your request. The Plan says that 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 does not say in clear and accurate terms 
how much you should expect to pay for outpatient hospital services.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $226 
deductible for outpatient hospital services. The Plan contract does not clearly say how much enrollees must pay 
for outpatient hospital services. This means that the Plan did not follow Medicare rules for disclosure of cost 
sharing information. Therefore, we decided that the Plan has to waive the cost share for each outpatient clinic 
visit provided from March 27, 2023, to April 6, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 17, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration for the denied 
claim. 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 office visit provided on January 17, 2023, by 
an OON provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the cost-sharing for outpatient hospital services provided on October 19, 
2022. 
 
You asked the Plan to waive the cost-sharing for outpatient hospital services. You say that you had no 
procedures or vaccines done on this date. The Plan denied your request. The Plan says that the cost-sharing 
amount you are being charged is correct. 
 
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. The Plan did not submit any supporting records to confirm that the services 
billed on this claim were actually performed. You say that you did not receive these services on this date. 
Without supporting medical records, we cannot determine whether the billed services should have been 
covered by the Plan with cost-sharing applied. Therefore, the Plan has not shown that its decision to ask you to 
pay $62.77 cost-sharing for this claim is correct or justified. Therefore, we decided that the Plan has to waive 
the cost-sharing for outpatient hospital services provided on October 19, 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: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the office visit (99205) provided on June 27, 
2022. 
 
You asked the Plan to waive the cost share for the physician service. You say that you feel you should not be 
responsible for this $25 copayment for an office visit. 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 specialist visit.  
 
You have been asked to pay a $25 copayment for the physician service. This service falls within the Physician 
specialist visit 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 office visit (99205) 
provided on June 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Orthosis (L8702). 
 
You asked the Plan to pre-approve the MyoPro orthosis. You say that this item is medically necessary. The 
Plan denied your request. The Plan says this item is considered experimental. 
 
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 the MyoPro orthosis. Our reviewer says 
that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found this item is considered experimental. 
 
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 MyoPro orthosis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the MyoPro Orthosis (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infusion pump services (96365, 96366, and 96521) provided 
on April 6, 2023. 
 
You asked the Plan to pay for 96365, 96366, and 96521. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the records do not support the codes billed. 
 
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 96365 is intravenous infusion, for therapy, prophylaxis, 
or diagnosis; initial, up to 1 hour. The CPT Code Manual definition of code 96366 is intravenous infusion, for 
therapy, prophylaxis, or diagnosis; each additional hour. The CPT Code Manual definition of code 96521 is 
refilling and maintenance of portable pump. 
 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 96365, 96366, and 96521. Our reviewer says that these codes 
do not meet criteria for payment. Our reviewer found the procedure report describes intravenous insulin 
treatment for an outpatient. There are more appropriate codes to report for the services provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 96365, 96366, and 96521 have not been met. Therefore, we decided that the 
Plan does not have to pay for infusion pump services (96365, 96366, and 96521) provided on April 6, 2023.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to reduce the coinsurance for dental services. We decided that the Plan does not 
have to waive the coinsurance for dental services.  
 You asked the Plan to waive the coinsurance for dental services provided on April 12, 2023, by an out-of-
network provider. You say that if you would have known that this would have been how much you owed you 
would not have had it done. The Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to reduce the coinsurance for dental services.  
 
The Plan follows Medicare rules. Medicare rules say that there is a 20% coinsurance for covered dental 
services provided by an out-of-network provider. 
 
Therefore, we decided that the Plan has to waive the coinsurance for dental services.  
 
We also decided that the Plan does not have to waive the coinsurance for dental services. 
 
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% 
coinsurance of the allowed amount for dental services. The total allowed amount $327. The total amount you 
are being asked to pay is $65.40 ($327 x 20% = $65.40). Therefore, we decided that the Plan does not have to 
waive the coinsurance for dental services. 
 
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.