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

 
We decided that the Plan does not have to waive the coinsurance for a heart pacer, durable medical equipment 
(DME) provided on January 24, 2021. 
 
You asked the Plan to waive the coinsurance for a heart pacer (DME). You say that you should not have this 
coinsurance amount. The Plan denied your request. The Plan says the coinsurance applied was 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 20% 
coinsurance for Durable Medical Equipment (DME) and Related Supplies. The allowed amount of this item is 
$2931.45 resulting in a coinsurance amount of $586.29. ($2931.45 x 20% = $586.29) 
 
You have been asked to pay 20% coinsurance for a heart pacer (DME). A heart pacer (DME) falls within the 
Durable Medical Equipment (DME) 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 heart pacer, durable medical equipment (DME) provided on January 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intermittent limb compression device (E0676) provided to 
the enrollee on December 8, 2021. 
 
You asked the Plan to pay for the device. You say that this is medically necessary to stimulate circulation, and 
reduce the chances of deep venous thrombosis. The Plan denied your request. The Plan says this item is not 
covered by Medicare. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for an intermittent limb compression device (E0676) provided to the enrollee on December 8, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
December 16, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you had to return to the ER two days 
later. You say that you should not pay this copayment since the problem was not addressed correctly. 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 emergency room visit.  
 
You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the Emergency Care 
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 emergency room (ER) visit 
provided on December 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on November 8, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says in addition to single gene testing, panels that include the FANCC gene are a statutorily excluded 
service. 
 
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 pay for 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 enrollee has non-small cell lung cancer, squamous type. Testing for the FANCC gene would not 
be actionable, and thus not medically necessary according to the National Comprehensive Cancer Network 
(NCCN) guidelines. 
 
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 pay for laboratory services provided to the enrollee on November 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you should not have an 
ambulance copayment. The Plan denied your request. The Plan says you were charged this cost sharing 
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 $300 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $300 for these 
services. 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 ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on  
September 2, 2021. 
 
You asked the Plan to pay for a domiciliary or rest home visit. The Plan denied your request. The Plan says and 
it was determined the services were not urgent or emergent and the services could have been rendered by a Plan 
participating 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 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 a domiciliary or rest home visit provided on September 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (K0862, 
E2361, E1028, E2313, E1007, E2311, E0955, E1012, E2603). 
 
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that the requested 
power wheelchair is medically necessary. The Plan denied your request. The Plan says the requested power 
wheelchair does not meet criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 
 
 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 group 3 power wheelchair and 
accessories. Our reviewer says that the items are not medically necessary. Our physician reviewer found there 
is documentation that you have a personal mobility deficit that impairs participation in mobility related 
activities of daily living such as toileting, feeding, grooming and bathing in customary locations within the 
home. Your mobility deficit cannot be helped by the use of a walker, cane or manual wheelchair due to your 
amputation. Provided records do not document a neurological disease, myopathy or congenital skeletal 
deformity causing your mobility limitation; you may qualify for an alternative type of power mobility device 
instead. 
 
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 group 3 power wheelchair and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (K0862, E2361, 
E1028, E2313, E1007, E2311, E0955, E1012, E2603).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from March 1, 2022, to 
March 2, 2022. 
 
You asked the Plan to pay for inpatient hospital care. The Plan denied your request. The Plan says the service 
sought or obtained by the member was or will be rendered by a provider who is not under contract with the 
Medicare Health Plan. 
 
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 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 inpatient hospital care provided from March 1, 2022, to  
March 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on  
October 13, 2021. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that the providers rely on facility staff 
to verify eligibility and obtain authorization from the patients insurance company. The Plan denied your 
request. The Plan says the information received did not provide just cause for the services to be rendered 
without obtaining prior authorization. The services were not urgent or emergent and the services could have 
been rendered by a Plan participating 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 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 a domiciliary or rest home visit provided on October 13, 2021.
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 requested are medically necessary. The 
Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services you are requesting do 
not meet the requirements for approval. 
 
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 review has determined that the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable 
expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for colonoscopy/endoscopy services billed with codes 45381 and 
45380 for date of service July 19, 2021. 
 
You asked the Plan to pay for procedure codes 45381 and 45380. You say that these services were billed 
appropriately and should be paid. The Plan denied your request. The Plan says this claim was paid according to 
Medicare rules, and the payment for these endoscopy procedures are bundled. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at your request, the file and Medicare rules. Based on this information we have determined that 
Medicare criteria for coverage have not been met. Specifically, the codes at issue on this claim have an 
indicator of 3 and the same base endoscopy code. The record clearly indicates that the Plan paid the full value 
of the highest valued endoscopy, plus the difference between the next highest and base endoscopy. Therefore, 
we decided that the Plan does not have to pay for colonoscopy/endoscopy services billed with codes 45381 and 
45380 for date of service July 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from July 30, 2021, through 
August 2, 2021, at DRG 683. 
 
You asked the Plan to pay for inpatient services at DRG 683. You say that E87.2 is supported by the 
documentation, and you disagree with the DRG assignment. You say that the medical records should be 
reviewed and payment for the original DRG approved. The Plan denied your request. The Plan says secondary 
diagnosis code E87.2 is not supported. 
 
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.   
 
In this case, you billed the inpatient services with secondary diagnosis code E87.2, defined as acidosis. 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 services at DRG 683. Our reviewer 
says that the medical records do not support the secondary diagnosis of acidosis. Our physician reviewer found 
that laboratory testing was not found in the medical records to clinically support a diagnosis of acidosis. In 
addition, acidosis is not documented with a plan of care during the emergency department service or 
subsequent hospital visits and discharge visit.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient services provided from July 30, 2021, through August 2, 2021, at DRG 683.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing provided to 
the enrollee on August 25, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare Part B covers cardiovascular disease screening tests when ordered by the physician 
who is treating the beneficiary for the purpose of early detection of cardiovascular disease in individuals 
without apparent signs or symptoms of cardiovascular disease. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee is already at a high risk of cardiovascular disease based on what her medical history already reveals as she is already on high dose statin, is overweight, has hypertension and is 69 years of age. There is no 
change in treatment that would be expected based on the results of this genetic testing that would effectively 
not already be recommended for her now. Therefore, without a clear clinical reason for this genetic testing, it 
will be considered not medically 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 the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for cardiac risk assessment genetic screening testing provided to the enrollee on August 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on  
January 31, 2022. 
 
You asked the Plan to pay for a domiciliary or rest home visit. The Plan denied your request. The Plan says the 
Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent 
care and pre-approved care. The Plan says that the Plan has also determined that these services are not urgent 
or emergent, nor were they approved in advance. 
 
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 did not pre-approve the 
service 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 a domiciliary or rest home visit provided on January 31, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the occlusal guardhard appliance, full arch (D9944) provided on 
March 3, 2022. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided the medical records that pertain to this 
case in order for our organization to determine your eligibility for the item at issue. Therefore, we decided that 
the Plan has to pay for the occlusal guardhard appliance, full arch (D9944) provided on March 3, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2 units of procedure code 29580 billed on March 14, 2022. 
 
You asked the Plan to pay for 2 units of procedure code 29580. You say that the enrollee has bilateral edema 
and bilateral venous insufficiency with ulcers. You say that the notes should be reviewed and both lines of 
29580 reprocessed for payment. The Plan denied your request. The Plan says a bilateral surgical procedure 
must be reported with 1 unit of service and modifier 50 (bilateral modifier).  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 29580 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 2 units of 
procedure code 29580 have not been met. Therefore, we decided that the Plan does not have to pay for 2 units 
of procedure code 29580 billed on March 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit and continuous glucose 
monitoring analysis on January 24, 2022. 
 
You asked the Plan to waive the copayment for an office visit and continuous glucose monitoring analysis. You 
say that you would like to appeal the cost share. The Plan denied your request. The Plan says the copayments 
applied are 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 
copayment for continuous glucose monitoring analysis (95251) and a $35 copayment for an office visit (99214) 
for an office visit and continuous glucose monitoring analysis. The copayment for the continuous glucose 
monitoring analysis is $36.80 which is less than the allowed amount of $75.  The member responsibility is 
$71.80. 
 You have been asked to pay a $75 copayment for continuous glucose monitoring analysis (95251) and a $35 
copayment for an office visit (99214) for an office visit and continuous glucose monitoring analysis. an office 
visit and continuous glucose monitoring analysis falls within the Outpatient diagnostic tests and therapeutic 
services and supplies and the Physician/Practitioner services, including doctors office visits benefit categories. 
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 office visit and continuous glucose monitoring analysis 
on January 24, 2022.