Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the enrollee is in the hospital and needs the 
requested ventilator for discharge. You say that the clinical information provided supports the need for the 
requested device. The Plan denied your request. The Plan says the requested device is being used in the bilevel 
positive airway pressure (BiPAP) mode rather than as a home ventilator. The Plan says that this is, therefore, 
not a covered benefit. 
 
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 a ventilator. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found a home ventilator is not medically 
necessary.  The enrollee has very severe obesity, obesity hypoventilation syndrome (OHS), probable obstructive sleep apnea (OSA), and cardiomyopathy.  Recently hospitalized with chronic heart failure (CHF) 
exacerbation, arterial blood gasses (ABGs) consistent with acute on chronic hypercarbic respiratory failure.  
The patient improved with AVAPS/BiPAP and diuresis.  ABG from 5 years ago was consistent with chronic 
carbon dioxide (CO2) retention.  The enrollee may benefit from BiPAP with average volume-assured pressure 
support (AVAPS) during sleep.  This has not been tried as an outpatient. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 provided on June 14, 2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was seen by multiple providers on 
the same day. The Plan denied your request. The Plan says an appropriate modifier was not billed. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 99232 was not billed with a modifier to indicate a separate identifiable evaluation and 
management service was provided on the same day as another evaluation and management service. Based on 
this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 99232 provided on June 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not 
meet the Medicare criteria for admission to an inpatient rehabilitation facility. 
 
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 does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for syncope, weakness, and orthostatic hypotension. Medical problems are stable. There 
are no complex nursing or rehabilitation needs. While the enrollee has a need for physical or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the denial of transurethral waterjet ablation of prostate was appropriate given the clinical 
scenario. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the records do not show that the enrollee has a prostate volume of 30-150cc by transrectal ultrasound 
(TRUS). The records also show that the enrollee has a diagnosis of prostate cancer which 
excludes transurethral waterjet ablation of prostate. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transurethral waterjet ablation of prostate for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9500 billed for date of service January 20, 
2022, to January 26, 2022. 
 
You asked the Plan to pay for procedure code S9500. You say that you believe this is a valid code. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9500 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9500 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9500 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9500 billed for date of service January 20, 2022, to January 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenomics testing provided on May 4, 2022. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says this testing is 
not a covered screening service. 
 
The Plan must follow Medicare rules. Medicare rules say that pharmacogenomics testing is only covered under 
certain medical indications.  
 
We looked at the file and Medicare rules. The records show that the enrollee wanted to determine whether the 
medications were offering the most therapeutic response. Medications should be provided based on the 
presence of a diagnosis and should be adjusted based on a response to the medication. The records do not show 
that there was a gene-drug interaction with the enrollees medications.  Based on this information, we decided that Medicare rules for coverage of the testing services have not been 
met. Therefore, we decided that the Plan does not have to pay for the pharmacogenomics testing provided on 
May 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custodial care facility visit provided on March 9, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for a custodial care facility visit. You say that the service was medically necessary, 
and you are appealing with medical notes. The Plan denied your request. The Plan says the enrollee must 
receive care from a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a custodial care facility visit provided on March 9, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for an overpayment of your coinsurance for a 
cystoscopy, biopsy, ultrasound, and urinalysis provided on June 8, 2022. 
 
You asked the Plan to reimburse you for an overpayment of your coinsurance for a cystoscopy, biopsy, 
ultrasound, and urinalysis. You say that you overpaid the provider, and you would like to be reimbursed. 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 20% 
coinsurance for outpatient diagnostic tests and therapeutic services and supplies.  
 
 
 
 
 You have been asked to pay $93.59 for a cystoscopy, biopsy, ultrasound, and urinalysis. These items/services 
fall 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 reimburse you for an overpayment of your coinsurance for a cystoscopy, biopsy, ultrasound, 
and urinalysis provided on June 8, 2022. Please note that the Plan confirmed with the providers office that you 
overpaid for these services and a partial refund has been initiated.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has tried and failed 
conservative treatment. The Plan denied your request. The Plan says the procedure does not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
The file shows that an Intracept intraossesous ablation of the basivertebral nerve was requested. 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 requested services. Our physician reviewer found 
that the Intracept procedure is experimental. Therefore, the request is not considered medically reasonable or 
necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for dialysis services provided from April 1, 
2021, to April 29, 2022. 
 
You asked the Plan to waive the coinsurance for dialysis services. You say that this should be covered. The 
Plan denied your request. The Plan says the cost sharing will be applied according to the Plan contract. 
 
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 20% 
coinsurance for renal dialysis services.  
 
 
 
 You have been asked to pay 20% coinsurance for dialysis services. This item/service falls within the Services 
to treat kidney disease 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 dialysis 
services provided from April 1, 2021, to April 29, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient specialist visits provided on June 
15, 2022 to June 17, 2022. 
 
You asked the Plan to waive the copayment for the outpatient specialist visits. You say that the services should 
be covered as you disagree with the denial. 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 $40 
copayment for Physician/Practitioner services, including doctors office visits, specifically specialist visits.  
 
 
  You have been asked to pay an $80 copayment for two outpatient specialist visits. This item/service falls 
within the Physician/Practitioner services, including doctors office visits, specifically specialist visits benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for outpatient specialist visits provided on June 15, 
2022 to June 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) and psychotherapy service (90824) 
provided on May 20, 2022, by an out-of-network (OON) provider. 
 You asked the Plan to pay for the physician services. You say that you would like this claim to be paid. You 
also say that you really need to be seeing this provider. The Plan denied your request. The Plan says the claim 
processed correctly. 
 
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 services at 
issue. We found no exception that would require the Plan to pay for these services. Additionally, there were no 
medical records received to support that the services were medically necessary. Therefore, we decided that the 
Plan does not have to pay for the office visit (99214) and psychotherapy service (90824) provided on May 20, 
2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance on May 27, 2022. 
 
You asked the Plan to waive the copayment for ambulance. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment per one-way trip for Medicare-covered ambulance services. Covered ambulance services include 
fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that can provide 
care if they are furnished to a member whose medical condition is such that other means of transportation could 
endanger the persons health or if authorized by the plan. 
 
You have been asked to pay a $350 copayment for ambulance. This item/service 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 on May 27, 
2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services provided on June 29, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the services provided. You say that the treatment was approved. The Plan denied 
your request. The Plan says the services were provided by a non-contracted provider. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the outpatient mental health services provided on June 29, 2022, 
by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from April 29, 2022, to May 28, 
2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that the date 
on the NOA needs to match the admit date on the final claim. 
 
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. 
 
We looked at the file and the rules. The Plan denied services as the admission date on the notice of admission 
did not match the date on the final claim. The case file does not include the submitted notice of admission to 
show that the dates were inconsistent. The Plan has not made reasonable and diligent efforts to gather and 
forward to us information regarding their decision to deny your request.  Therefore, we decided that the Plan 
has to pay for the home health services provided from April 29, 2022, to May 28, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on January 12, 2021, to February 23,
2021, by an out-of-network (OON) provider outside of the United States.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
urgent/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 services at issue in this appeal. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Additionally, the
Plan does not cover non-emergent services provided outside of the United States. Therefore, we decided that
the Plan does not have to pay for the services provided on January 12, 2021, to February 23, 2021, by an outof-network (OON) provider outside of the United States.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing services provided on March 14, 2022. 
 You asked the Plan to pay for the testing services. You say that the test identifies potential targeted therapy 
options. The Plan denied your request. The Plan says the test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The records provided show the testing is not FDA approved. The 
testing was also billed with a code that is considered unlikely to impact therapeutic decision making. Based on 
this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for the laboratory testing services provided on March 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on April 2, 
2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you were transported from 
one hospital to another due to trauma and feels he should not be responsible for the copayment. 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 $275 
copayment for Ambulance services/per one-way trip by ground or air ambulance.  
 
You have been asked to pay a $275 copayment for ambulance services. This item/service falls within the 
Ambulance services/per one-way trip by ground or air ambulance 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 services provided on April 2, 2022.