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

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) 
and intraoral - periapical each additional radiographic image (D0230) provided April 25, 2022. 
 
You asked the Plan to pay for the periapical x-rays. You say that the documentation you have indicates that 
these services are covered. The Plan denied your request. The Plan says these services are not covered under 
your benefits. You did not purchase the additional optional dental rider. 
 
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, the requested items or services are not 
among those covered under this benefit. The documentation you submitted which shows coverage for these 
services is listed under the Plans optional Platinum Dental Rider which must be purchased. You have not 
purchased this additional dental coverage. Therefore, we decided that the Plan does not have to pay for the 
intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic 
image (D0230) provided April 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on May 23, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for podiatry services. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of payment for these services is correct, because this 
provider is out-of-network with the Plan and authorization was not obtained. 
 
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 podiatry services provided on May 23, 2022 by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 21, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the referring physician ordered the test to be 
done and you would like the claim to be paid. The Plan denied your request. The Plan says the rendering and 
referring providers are both OON providers and there was no approved authorization. Also, the service 
rendered was not 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 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 February 21, 
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 wound debridement services provided on June 15, 2022 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound debridement services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
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 wound debridement services provided on June 
15, 2022 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not require intensive physician and nursing oversight in an IRF. While the enrollee may 
benefit from additional multiple therapies, including physical and occupational therapy, the documentation 
does not reveal that the enrollee requires this therapy on an intensive IRF level. The documentation does not 
support the enrollee could tolerate an intensive therapy program in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cala Trio nerve stimulation device provided on March 
21, 2022. 
 
You asked the Plan to pay for the Cala Trio nerve stimulation device. You say that You say that the patient has 
been using the device and seeing improvement and control over their hand essential tremor. The Plan denied 
your request. The Plan says this device is investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that electrical stimulators to treat motor function 
disorders are not covered.  The Cala Trio device is an electrical stimulator that was provided to the member for 
the sole purpose of treating essential tremor.  Essential tremor is a motor function disorder. We looked at the 
file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Cala 
Trio nerve stimulation device have not been met. Therefore, we decided that the Plan does not have to pay for 
the Cala Trio nerve stimulation device provided on March 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on April 25, 
2022. 
 
You asked the Plan to waive the copayment for urgent care visit. You say that you could not get an 
appointment at your doctor's office so do not think this copayment was fair. 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 $50 
copayment for each urgent care visit.  
 
You have been asked to pay $50 copayment for urgent care visit. Urgent care visit falls within the Urgently 
Needed Services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an urgent care visit 
provided on April 25, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided from November 8, 2021, to 
December 20, 2021. 
 
You asked the Plan to pay for psychotherapy services. You say that the requested psychotherapy services were 
a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for 
psychotherapy services have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy services have not been met. Specifically, the record does not include documentation 
of a consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare 
rules. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided from 
November 8, 2021, to December 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge services rendered on December 7, 
2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that observation code 99217 shall not be reported when a 
patient receives observation care for less than 8 hours on the same calendar date for initial observation care. 
 
We looked at the file and Medicare rules. The file shows that procedure code 99217 was billed on the same 
date as the initial observation care. Based on this information, we decided that Medicare rules for coverage of 
these services have not been met. Therefore, we decided that the Plan does not have to pay for the hospital 
discharge services rendered on December 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services with diagnosis related group 
(DRG) 291 provided from January 17, 2021, to January 20, 2021. 
 
You asked the Plan to pay for the inpatient hospital services with DRG 291. You say that the records support 
the billing of DRG 291. The Plan denied your request. The Plan says the records do not support the billing of 
DRG 291, and the Plan will pay for these inpatient services with a DRG of 293. 
 
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 inpatient hospital services with 
diagnosis related group (DRG) 291 provided from January 17, 2021, to January 20, 2021, have been met. 
Complete medical records were requested by the Plan and never received. Therefore, we decided that the Plan 
does not have to pay for the inpatient hospital services with diagnosis related group (DRG) 291 provided from 
January 17, 2021, to January 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adult day care services provided on December 31, 2021. 
 
You asked the Plan to pay for the adult day care services. You say that you would like this date of service to be 
approved for coverage. The Plan denied your request. The Plan says this claim denied correctly, as the benefit 
limit was reached. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the adult day care services have not been met. Specifically, the Evidence of Coverage states adult 
day center coverage is available for up to 1 visit per week. The record shows that this December 31, 2021, date 
of service fell in the same week as the December 29, 2021, date of service which was already paid by the Plan. 
Therefore, we decided that the Plan does not have to pay for the adult day care services provided on December 
31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an eye exam provided on March 22, 2022, 
and March 29, 2022. 
 
You asked the Plan to waive the copayments for an eye exam. You say that this should be a $10 copayment, if 
there is one at all. The Plan denied your request. The Plan says the copayments that were applied were 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 $15 
copayment for vision services.  
 
You have been asked to pay a $30 copayment for an eye exam ($15 x 2 = $30). An eye exam falls within the 
Vision 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 an eye exam provided on 
March 22, 2022, and March 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge services rendered on October 5, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99239 is not supported. 
 
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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, there is no documentation of 
more than 30 minutes of hospital discharge management. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for the hospital discharge services rendered on October 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine foot care services provided on February 18, 2022. 
 
You asked the Plan to pay for routine foot care services. You say that this patient was diabetic, so this should 
be covered. The Plan denied your request. The Plan says this service exceeded the frequency requirements.  
This service had already been performed within the preceding 60 days (on December 31, 2021). 
 
The Plan must follow Medicare rules. Medicare rules say that routine foot care services are considered 
medically necessary once every 60 days.  More frequent services will be considered not medically necessary.  
In this case, the patient had already received routine foot care on December 31, 2021.  The services at issue in 
this appeal occurred on February 18, 2022, which is within the 60-day period. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of routine foot care services have not been met. Therefore, we decided that the Plan does not have to 
pay for routine foot care services provided on February 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of 
the brain (including brain stem); without contrast material (70551) provided on April 14, 2022. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $200 
copayment for each Medicare-covered diagnostic radiology service other than computed tomography (CT) 
scans.  
 
You have been asked to pay a $200 copayment for the Medicare-covered diagnostic radiology service 
provided. 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 magnetic resonance imaging 
(MRI) of the brain (including brain stem); without contrast material (70551) provided on April 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical pathology services (88305) provided on September 
2, 2021. 
 
You asked the Plan to pay for pathology services. You say that this service is supported in the medical record. 
The Plan denied your request. The Plan says this service was not billed in accordance with Medicare rules. 
Code 88305 is missing a necessary modifier for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that payment is not made under the physician fee schedule for Technical Component (TC) services 
furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital 
inpatient and outpatient settings. In addition, TC services furnished by independent laboratories to hospital 
patients are not payable by the MAC. 
 
We find that CPT code 88305 is a physician pathology service which has both a professional component (PC) 
and a technical component. This service was not billed with modifier 26 to indicate that only the professional 
component payment is requested. This means that payment is requested for both the PC and TC of this service. 
However, this service was provided to an enrollee who was in an outpatient hospital setting at the time the 
sample was collected, which means that the TC component is bundled into the facility payment. The TC 
portion of this service is not separately payable, and therefore this service is not supported as billed. Based on 
this information, we decided that Medicare rules for coverage of pathology services have not been met. 
Therefore, we decided that the Plan does not have to pay for surgical pathology services (88305) provided on 
September 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on February 28, 2021. 
 
You asked the Plan to pay for the medical services. You say that the medical records support payment. The 
Plan denied your request. The Plan says you billed with an incorrect POS on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill the appropriate Place of 
Service (POS) code to represent where the service occurred. POS code 21 indicates that the service occurred in 
an inpatient hospital setting.  POS code 22 indicates that the service occurred in an on-campus outpatient 
hospital setting. Records show that you billed with POS 21. However, the records also show that this patient 
was in observation at the hospital, which is an outpatient setting. This means that an outpatient hospital POS 
should have been used on the claim.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided on February 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthotic items provided on April 19, 2022. 
 
You asked the Plan to pay for orthotics. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the documentation submitted does not support the codes billed on this 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that proof of delivery is required for payment of 
durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items.  
 
We looked at the file and Medicare rules. The record submitted does not include valid proof of delivery for the 
specific DMEPOS items billed on this claim. Based on this information, we decided that Medicare rules for 
coverage of orthotics have not been met. Therefore, we decided that the Plan does not have to pay for orthotic 
items provided on April 19, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the outpatient clinic visit provided on April 
14, 2022. 
 
You asked the Plan to waive the deductible for the outpatient clinic visit. You say that your visit was for a 
wellness visit and there should not be a deductible charged. The Plan denied your request. The Plan says the 
proper deductible was charged for the service that was billed. 
 
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 $550 deductible which applies to What is your plan deductible. Prior 
to the date of service $0 was paid towards the yearly deductible. The total amount charged was $129.97 which 
was applied to the yearly deductible of $550. After the date of service, the total amount left on the yearly 
deductible was $420.03 ($550 yearly deductible - $129.97 paid towards deductible). 
 
  The item or service you asked the Plan to waive the deductible for falls within the What is Your Plan 
Deductible benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $550 deductible which applies to the outpatient clinic visit. This cost sharing is a contractual 
obligation that had not been met at the time the outpatient clinic visit was received on April 14, 2022. 
Therefore, we decided that the Plan does not have to waive the deductible for the outpatient clinic visit 
provided on April 14, 2022.