Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital care (99223) provided on January 22, 2022. 
 
You asked the Plan to pay for the hospital care. You say that you would like this claim reprocessed for medical 
necessity. The Plan denied your request. The Plan says this code has been billed with an inappropriate primary 
diagnosis. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that certain conditions have both an underlying etiology and multiple body system manifestations 
due to the underlying etiology. For such conditions, the ICD-10-CM has a coding convention that requires the 
underlying condition be sequenced first, if applicable, followed by the manifestation. 
 
We looked at the file and Medicare rules. Specifically, this case has been billed with a primary diagnosis code 
F05 defined as delirium due to known physiological condition. However, the underlying physiological 
condition must be the primary code which was not the case for this claim. Based on this information, we 
decided that Medicare rules for coverage of the hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the hospital care (99223) provided on January 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the home ventilator is necessary to treat 
the enrollee's chronic obstructive pulmonary disease (COPD). The Plan denied your request. The Plan says the 
request for a home mechanical ventilator set in TTV-VAPS AE mode that could be delivered by bilevel 
positive airway pressure (BiPAP) is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found a home ventilator is not medically necessary.  This enrollee has severe COPD. However, there 
is no arterial blood gases (ABG) done as an outpatient while stable to document chronic carbon dioxide (CO2) 
retention. The only blood gas results in the record are venous. If the enrollee does have chronic CO2 retention, 
BiPAP therapy can provide the average volume-assured pressure support (AVAPS) mode. Medicare does not cover a home ventilator when used as BiPAP. The denial is upheld. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from January 17, 2022, through 
February 21, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that you are appealing psychotherapy due to marital 
issues. You say that you just need someone to talk to and the claim should be reprocessed. The Plan denied 
your request. The Plan says services of a licensed marriage and family therapist and a licensed professional 
counselor are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that there are certain individuals and entities that 
frequently attempt to enroll in Medicare but are not eligible to do so.  
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, a licensed marriage and family therapist is not a 
covered provider type. Therefore, we decided that the Plan does not have to pay for psychotherapy provided 
from January 17, 2022, through February 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve RFA to the SI joint. You say that this procedure is medically necessary for 
the enrollee's pain management. The Plan denied your request. The Plan says the requested procedure is 
considered experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve RFA to the SI joint. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is a 73-year-old gentleman who has sacroiliitis. Currently, he takes 
over-the-counter medications for pain. He had 2 diagnostic SI joint blocks which provided 95% pain relief each 
time. The request is for RFA of the lateral sacral branches. This is considered experimental/ investigational 
because of the wide variation in efficacy reported in the peer reviewed literature. Therefore, the request is 
deemed not medically reasonable or 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 RFA to the SI joint have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) joint.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
February 10, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the cost is too much 
to afford. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 $90 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $90 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance 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 
ambulance transportation provided on February 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a comprehensive audiometry evaluation 
provided on January 19, 2022. 
 
You asked the Plan to waive the copayment for the comprehensive audiometry evaluation. You say that prior to 
this test you called the Plan to make sure the test was covered with no copay and confirmed the doctor was 
in-network. The Plan denied your request. The Plan says the claim processed with the correct copayment. 
 
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 $30 
copayment for Hearing Services-Medicare-covered hearing exam (diagnostic hearing exam) to see if you need 
medical treatment.  
 
You have been asked to pay a $30 copayment for the comprehensive audiometry evaluation. The 
comprehensive audiometry evaluation falls within the Hearing Services-Medicare-covered hearing exam 
(diagnostic hearing exam) to see if you need medical treatment 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 a comprehensive audiometry evaluation provided on January 19, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ambulance transportation provided from 
January 17, 2022, to January 25, 2022. 
 
You asked the Plan to waive the copayments for the ambulance transportation. You say that the cost is too 
much to afford. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
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 $90 
copayment for each one-way ambulance trip.  
 
The file shows you had 3 separate ambulance trips from January 17, 2022, to January 25, 2022. Therefore, you 
have been asked to pay a $90 copayment for each of the ambulance transportation services, for a total of $270. 
The ambulance transportation falls within the Ambulance 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 copayments for ambulance transportation provided from January 17, 2022, to January 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided on February 11, 2022. 
 
You asked the Plan to pay for the acupuncture services. You say that this claim should be paid by the Plan. The 
Plan denied your request. The Plan says acupuncture services are only covered for chronic low back pain. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the claim has been billed with a diagnosis of chronic 
knee pain. Acupuncture services are not covered by Medicare or the Plan for any condition other than chronic low back pain. Therefore, we decided that the Plan does not have to pay for the acupuncture services provided 
on February 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on February 8, 2022. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this particular testing is statutorily 
excluded from coverage. 
 
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 genetic testing services provided 
on February 8, 2022, have been met. In this case, no clinical records have been provided from the enrollees ordering provider that would establish the medical necessity of the provided genetic testing. Therefore, we 
decided that the Plan does not have to pay for the genetic testing services provided on February 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for specialist office visits and an 
electrocardiogram (EKG) provided by an out-of-network (OON) provider from January 7, 2022, to February 1, 
2022. 
 
You asked the Plan to waive the coinsurance for the OON office visits and EKG. You say that you were not 
aware the provider was out-of-network. The Plan denied your request. The Plan says the correct coinsurance 
was applied. 
 
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 for out-of-network provider services. 
 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for out-of-network imaging and testing services. 
 
Service Allowed Amount 20% Coinsurance (OON) 
Office Visit  January 7, 2022 $170.96 $33.75 
EKG  January 7, 2022 $15.09 $2.98 
Office Visit  January 26, 2022 $170.57 $33.67 
Office Visit  February 1, 2022 $151.87 $30.37 
Total:  $100.77 
 
The file shows that the Plan determined the provider is out-of-network. Therefore, you have been asked to pay 
$100.77, which is 20% of the allowed amount for the OON office visits and EKG. The OON office visits fall 
within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. The OON EKG 
falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 coinsurance for specialist office visits and an electrocardiogram (EKG) 
provided by an out-of-network (OON) provider from January 7, 2022, to February 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you've had bilateral foot problems for over 
fifteen years and had two surgeries on the left foot: a bunionectomy, and 2nd and 3rd toe fusion with ligament 
repair due to severe hammer toes and torn ligaments. And currently you have a bunion progressing on your 
right foot. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a knee orthosis (brace) provided on 
January 31, 2022. 
 
You asked the Plan to waive the coinsurance for the knee brace. You say that you were not aware of the 
coinsurance when you received the brace. The Plan denied your request. The Plan says the correct coinsurance 
was applied. 
 
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 for prosthetic devices and related supplies, including braces.  
 
You have been asked to pay $111.95, which is 20% of the allowed amount for the knee brace ($559.76 allowed 
amount x 20% coinsurance = $111.95). The knee brace falls within the Prosthetic Devices and Related 
Supplies 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 coinsurance for a knee orthosis (brace) 
provided on January 31, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy 
assistant on March 25, 2020. 
 
You asked the Plan to pay for physical therapy services. You say that the medical records required to reprocess 
the denied claim are attached. The Plan denied your request. The Plan says the code is not appropriate for the 
service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) 
shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they 
do not meet the qualifications of a therapist. 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services 
provided by a physical therapy assistant on March 25, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 16, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. 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 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 July 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bilateral upper lid blepharoplasty and bilateral brow 
lift. 
 
You asked the Plan to pre-approve a bilateral upper lid blepharoplasty and bilateral brow lift. You say that the 
enrollee has the underlying condition of retinitis pigmentosa, with visual impairment manifesting as night 
blindness and visual field loss. You say that, although surgical correction cannot repair his underlying visual 
impairment secondary to retinitis pigmentosa, the lifting of the eyebrow and blepharoplasty can allow for more 
light to enter his eyes for more clarity of his central working vision. The Plan denied your request. The Plan 
says the requested services are not medically necessary because the documentation does not indicate potential 
correction of condition with eyelid taping. 
 
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 bilateral upper lid blepharoplasty and 
bilateral brow lift. Our reviewer says that a bilateral upper lid blepharoplasty and bilateral brow lift are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has 
drooping upper eyelids that are causing irritation and obstructing vision. It is documented that taping of the upper eyelids did not result in improvement. Consequently, it is not reasonable to expect that lifting of the 
eyebrows and blepharoplasty would result in improvement for the enrollee. Lifting of the eyebrows and 
blepharoplasty are not accepted standards of medical practice for the treatment of visual impairment secondary 
to retinitis pigmentosa. 
 
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 bilateral upper lid blepharoplasty and bilateral brow lift have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a bilateral upper lid blepharoplasty and 
bilateral brow lift.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider. 
 
You asked the Plan to pay for the office visit provided by an out-of-network provider.. You say that there are 
no other doctor within 75 miles who takes your insurance, and this shouldnt be your responsibility. The Plan 
denied your request. The Plan says an in-network optometrist in your area was available. 
 
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 the office visit provided by an out-of-network 
provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for physical therapy (PT) services provided 
from March 7, 2022, to March 29, 2022. 
 
You asked the Plan to reduce the copayments for the PT services. You say that your copayments should only 
be $25. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 each therapy visit at an outpatient hospital.  
 
The file shows that the billed location code was for an outpatient hospital facility. Therefore, you have been 
asked to pay a $40 copayment for each of the 4 visits for the PT services, for a total of $160. The PT services 
fall within the Outpatient Rehabilitation 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 reduce the 
copayments for physical therapy (PT) services provided from March 7, 2022, to March 29, 2022.