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

 
We decided that the Plan does not have to waive the copayment for the scanning computerized ophthalmic 
diagnostic imaging (92134) provided on March 25, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic imaging. You say that you have always only 
paid for an office copay, and not individual services. The Plan denied your request. The Plan says the 
copayment amount you are being charged is correct. 
 
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 $75 
copay for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
 
 
 You have been asked to pay $33.97 for the diagnostic imaging. Diagnostic imaging falls within the Outpatient 
diagnostic tests and therapeutic services and supplies benefit category. The allowed amount of $33.97 that you 
have been asked to pay is less than the $75 copay the Plan contract states you are responsible for. You are also 
responsible for a $35 copay for the eye exam. 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 scanning 
computerized ophthalmic diagnostic imaging (92134) provided on March 25, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on January 26, 2022. 
 
You asked the Plan to pay for physical therapy services. You say that the physical therapy services were 
medically necessary. The Plan denied your request. The Plan says the provider is no longer credentialed or 
eligible for Medicare/Medicaid billing of services. The providers license has also been placed on permanent 
inactive status in the states of Missouri and Illinois; therefore, the billed services cannot be supported. 
 
The Plan must follow Medicare rules. Medicare rules say that outpatient rehabilitation therapy services must be 
provided by a qualified professional.  
 
 We looked at the file and Medicare rules. The file shows that this provider had their license suspended to 
perform physical therapy in South Carolina on the date of service in question. Based on this information, we 
decided that Medicare rules for coverage of physical therapy services have not been met. Therefore, we decided 
that the Plan does not have to pay for physical therapy services provided on January 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second unit of critical care, first hour (99291) billed for 
date of service February 25, 2022. 
 
You asked the Plan to pay for a second unit of 99291. You say that this service is supported in the record. The 
Plan denied your request. The Plan says the first unit of 99291 was paid on June 2, 2022. A second unit of 
99291 was billed for the same date and exceeds the number of units allowed per day based on Medicare rules. The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 99291 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of a second 
unit of 99291 have not been met. Therefore, we decided that the Plan does not have to pay for a second unit of 
critical care, first hour (99291) billed for date of service February 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 12, 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 the services billed are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on January 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 23, 2021, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. You say that you were unaware that they were not participating 
because you say you are in-network with the Plan. The Plan denied your request. The Plan says the out-of-
network 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 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 an office visit provided on March 23, 2021, by an 
OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from March 4, 2021, to 
March 8, 2021, as billed with Diagnosis Related Group (DRG) 871. 
 
You asked the Plan to pay for inpatient care as billed with DRG 871. You say that these services were 
medically necessary and are supported in the record. The Plan denied your request. The Plan says DRG 871 is not appropriate as the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical record. 
The Plan argues that DRG 369 is more appropriate in this case. 
 
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. 
 
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 inpatient care as billed with DRG 871. Our 
reviewer says that the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical records 
for this inpatient admission. Our physician reviewer found the provided hospital record does not support 
reporting a diagnosis of sepsis for this hospital encounter, despite presentation with cystitis/urinary tract 
infection. The more appropriate principal diagnosis for this hospital admission is either Esophagitis, 
unspecified with bleeding or acute cystitis with hematuria. The review has determined that the medical records 
did not support the billing of sepsis, unspecified organism (A41.9) 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care as billed with DRG 871 have not been met. Therefore, we 
decided that the Plan does not have to pay for inpatient hospital care provided from March 4, 2021, to March 8, 
2021, as billed with Diagnosis Related Group (DRG) 871.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 27, 2021. 
 
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 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 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for carpal tunnel surgery (64721) billed for date of service 
November 22, 2021. 
 
You asked the Plan to pay for carpal tunnel surgery. You say that you have provided medical records to support 
the services billed. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64721 is 1. The MAI value for this code is 2. You billed a second unit of 
this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
carpal tunnel surgery have not been met. Therefore, we decided that the Plan does not have to pay for carpal 
tunnel surgery (64721) billed for date of service November 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you feel that this CGM is necessary for your 
treatment. The Plan denied your request. The Plan says this is not covered for you because you do not require 
multiple insulin injections. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily administrations. Based on this information, we decided that Medicare rules for 
coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasonic guidance for radiation therapy (G6001). 
 
You asked the Plan to pre-approve ultrasonic guidance. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for coverage of 
the requested service have not been met. 
 
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 ultrasonic guidance. Our reviewer says 
that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that, when treating skin cancers, there is generally not a need for image-guided radiation 
therapy (IGRT) unless deep structures are being treated. In this case, IGRT would not be furnished in 
accordance with accepted standards of medical practice. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasonic guidance have not been met. Therefore, we decided that the Plan does 
not have to pre-approve ultrasonic guidance for radiation therapy (G6001).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit you had with an out-of-network doctor on 
March 24, 2022. 
 
You asked the Plan to pay for the office visit. You say that you had to go to this doctor because they are the 
only one able to prescribe the medications you need. The Plan denied your request. The Plan says this doctor 
has opted-out of Medicare, so no payment can be made. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a 
non-urgent, non-emergent situation by a provider who has opted out of the Medicare program. Therefore, we 
decided that the Plan does not have to pay for the office visit you had with an out-of-network doctor on March 
24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immunization services provided on March 30, 2022. 
 
You asked the Plan to pay for the services provided. You say that you had no knowledge that the shot would 
cost you. The Plan denied your request. The Plan says the vaccine is not covered. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services 
provided. The Plan follows the same rules.  
 
The file shows that a tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) was provided. The 
records do not show that you were injured or directly exposed to any illness related to the services provided. 
Therefore, we decided that the Plan does not have to pay for the immunization services provided on March 30, 
2022.  
 
Benefits for the services provided may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on March 18, 2022. 
 
You asked the Plan to pay for the services provided. You say that the services were rendered in the appropriate 
place of service. The Plan denied your request. The Plan says the code may not be paid if furnished to hospital 
outpatients. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 We find that CPT code 85060 was billed with an outpatient hospital place of service code (22). Payment is not 
recognized for hospital outpatient or non-hospital patients. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the pathology services provided on March 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical each additional radiographic image 
(D0230) and removal of residual tooth roots (cutting procedure) (D7250) provided March 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like an explanation of the denials. 
The Plan denied your request. The Plan says your benefit for the requested services have already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested services was exhausted on the same date of service, March 29, 2022. 
Therefore, we decided that the Plan does not have to pay for the intraoral - periapical each additional 
radiographic image (D0230) and removal of residual tooth roots (cutting procedure) (D7250) provided March 
29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on January 7, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 office visit at issue in this appeal. The Plan did not pre-approve the 
office visit at issue. We found no exception that would require the Plan to pay for the office visit. Therefore, we 
decided that the Plan does not have to pay for office visit provided on January 7, 2022, by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient chiropractic office visit (99212) provided 
January 14, 2022. 
 
You asked the Plan to pay for the chiropractic visit. You say that you thought you was covered for all of your 
extra medical needs without Medicare. You always went to the chiropractor and now you received a denial 
letter stating this visit was not covered. The Plan denied your request. The Plan says this service is not covered 
when rendered by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
 
 
 
 
 The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the outpatient chiropractic office visit (99212) provided January 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for anesthesia on February 24, 2022. 
 
You asked the Plan to waive the deductible for anesthesia. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
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 Outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers. The provider billed in the 
amount of $203.54 + $203.54 + $88.54, which equals $495.62. Therefore, results in the total cost sharing 
among of $495.62.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible which applies to 
Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. 
This cost sharing is a contractual obligation that had not been met at the time anesthesia was received on 
February 24, 2022. Therefore, we decided that the Plan does not have to waive the deductible for anesthesia on 
February 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services coded 99291 provided on February 
17, 2022. 
 You asked the Plan to pay for the critical care services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says in this case, the provider has not billed as 
required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 99291 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the 
critical care services coded 99291 provided on February 17, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown (D2740) for tooth #5. 
 
You asked the Plan to pre-approve a crown for tooth #5. You say that you need a crown for tooth #5 so you can 
eat. You also say that you are in pain and do not have any money to pay for the crown. The Plan denied your 
request. The Plan says that there is a cavity below the bone of your tooth. The Plan also says that the tooth will 
not last long because the cavity is below the bone. 
 
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 provide digital quality x-rays for this case. We asked for these 
x-rays, but they were not provided to us. Without this information we cannot determine that the requested 
service does not meet criteria and is not medically necessary. Consequently, the Plan has not substantiated their 
denial of payment in this case. Therefore, we decided that the Plan has to pre-approve a crown (D2740) for 
tooth #5.  
 
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.