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

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose 
monitor is medically necessary. The Plan denied your request. The Plan says there are network providers 
available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items at issue in this appeal. We found no exception that would require the Plan 
to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (K0553, K0554) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
November 17, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that the visit was a post 
operation follow up and there should be no copayment applied. The Plan denied your request. The Plan says it 
was verified through the provider that the enrollee received service from the provider and the enrollee had a 
surgical procedure done prior. Medicare defines the global period as that period of time during which a 
physician may not bill for related office visits. According to Medicare, the global period for procedure code 
52240 is the day of the surgery or procedure. There is no global period for this procedure. Therefore, the proper 
copayment was applied for the services rendered to the enrollee. 
 
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 $35 
copayment for each Medicare-covered specialist visit (including surgery second opinion, telehealth services, 
and urgently needed services).  
 You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls 
within the Physician/Practitioner services, including doctors office 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 a specialist office visit provided on November 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not 
require transfer to the LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for 
respiratory failure. The enrollee is not intubated/ventilated.  There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, 
there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH 
until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level 
of care for any ongoing long term care needs. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance transportation service 
(A0427) provided on October 25, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation service. You say that the services 
should be covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-
sharing applied correctly based on the services 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 $250 
copayment for Ambulance Services.  
 
 You have been asked to pay a $250 copayment for the ambulance transportation service. 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 ambulance transportation service (A0427) provided on October 
25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a continuous positive airway pressure 
(CPAP) device and supplies provided from September 27, 2021, to October 27, 2021. 
 
You asked the Plan to waive the coinsurance for the CPAP device and supplies. You say that you were 
informed that the cost would be 100% covered. The Plan denied your request. The Plan says the correct 
coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment (DME), including CPAP devices and related supplies. 
 
 Item/Supply Allowed Amount 20% Coinsurance 
CPAP Tubing $40.46 $8.09 
CPAP Face Mask $90.32 $18.06 
CPAP Disposable Filter $2.12 $0.42 
CPAP Humidifier $138.81 $27.76 
CPAP Device  September 27, 2021 $41.31 $8.26 
CPAP Device  October 27, 2021 $41.31 $8.26 
Total:  $70.85 
 
You have been asked to pay $70.85, which is 20% of the allowed amount for the CPAP device and supplies. 
The CPAP device and supplies fall 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 continuous positive airway pressure (CPAP) 
device and supplies provided from September 27, 2021, to October 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on October 31, 
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 the denied code remains 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 37609 is "Ligation or biopsy, temporal artery." 
 
We asked our coder 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 services at issue in 
this case were not supported by the medical records. Our reviewer found the operative report does not include 
documentation of temporal artery ligation or biopsy.  The report describes removal of foreign bodies from the 
scalp flap. Therefore, this procedure cannot be verified.  
 
 We looked at this coder'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 surgical services provided to the enrollee on October 31, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from January 30, 2020 to 
March 26, 2020. 
 
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 were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that home health services are pad base don a 30-day 
period of care. 
 
We looked at the file and Medicare rules. The file shows that the services were billed as a 57-day period of 
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 home health services rendered from 
January 30, 2020 to March 26, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient skilled nursing facility (SNF) 
care provided from July 16, 2021, through August 30, 2021. 
 
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 services 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $0 copayment per day, per stay, for days 1-20 and a $160 copayment per day, per stay, for days 21-
100, for skilled nursing facility care. Additionally, the most the enrollee will have to pay out-of-pocket for in-
network covered Part A and Part B services in the year 2021 is $3,200. 
 
  
The enrollee was asked to pay $2,178.40 ($160 copayment x 25 days) for the skilled nursing facility care 
provided. This amount is less than the applicable copayment for these services as the enrollee met the 
maximum out-of-pocket expense for the calendar year with this claim. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for the inpatient skilled nursing facility (SNF) care provided from July 16, 2021, 
through August 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
abdomen and pelvis provided on August 9, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you have only paid your copayments 
for the doctor visits previously. 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 $195 
copayment for diagnostic and nuclear medicine radiological services, including CT scans.  
 
 You have been asked to pay a $195 copayment for the CT scan. The CT scan falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for a computed tomography (CT) scan of the abdomen and pelvis provided on August 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from April 4, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from April 4, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from April 4, 
2022, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health 
treatment beyond the date in question of April 4, 2022, forward. Our physician reviewer found the enrollee did 
not require inpatient mental health treatment beyond April 4, 2022, as they were not a danger to themself or others 
and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was 
taking place beyond the date in question. It did not appear that the services for the dates in question were 
reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. 
 
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 psychiatric care from April 4, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from April 4, 2022, 
forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on 
September 27, 2021. 
 
You asked the Plan to pay for code 99153. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the review shows that the medical records provided 
represent professional charges; however, procedure code 99153 was provided in a facility with a place of 
service code of 21. Procedure code 99153 has a PC/TC Modifier Status of 3, which specifies a Technical Component only code. Therefore, we decided that the Plan does not have to pay for the moderate sedation 
services (99153) provided on September 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on October 8, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that it is the facilities responsibility to obtain prior 
authorization for the enrollee and the service was rendered in good faith. The Plan denied your request. The 
Plan says the rendering provider is an out-of-network provider 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 a home health visit provided on October 8, 2021, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say that RFA is covered when specific criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain. 
She had two sets of diagnostic medial branch blocks (MBBs) and the second set of blocks produced only 75 
percent pain relief. The Medicare criteria requires at least 80 percent pain relief from each set of blocks. The 
criteria are not met; therefore, RFA is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies/services necessary during the public 
health emergency billed for date of service October 11, 2021, with code 99072. 
 
You asked the Plan to pay for the additional supplies/services as billed. You say that the claim should pay an 
additional $1078.57. The Plan denied your request. The Plan says the claim was paid correctly at the Medicare 
allowed rate. No payment can be made for 99072. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
Code 99072 has a status indicator of "B" in the Medicare Physician Fee Schedule, meaning that payment for 
this is bundled with payment for other services. Based on this information, we decided that Medicare rules for 
coverage of the additional supplies/services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the additional supplies/services necessary during the public health emergency billed 
for date of service October 11, 2021, with code 99072.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6210) and two retainer crowns (D6750 x2). 
 
You asked the Plan to pre-approve the pontic and retainer crowns. You say that these services need to be 
processed under your supplemental dental coverage. The Plan denied your request. The Plan says these services 
are not covered under your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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. Therefore, we decided that the Plan does not have to pre-approve a 
pontic (D6210) and two retainer crowns (D6750 x2).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation (A0428) 
provided on September 16, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the services should 
be covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing 
applied correctly based on the services 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 $250 
copayment for Ambulance services.  
  
 You have been asked to pay a $226.97 copayment for the ambulance transportation, which is less than the 
standard $250. This means that you have been asked to pay the correct amount based on your contract with the 
Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, 
we decided that the Plan does not have to waive the copayment for ambulance transportation (A0428) provided 
on September 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on August 
3, 2021. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that the facility is an approved 
facility, and everything should have been paid in full. The Plan denied your request. The Plan says the proper 
copayment was applied for the service that was rendered. 
 
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 $35 
copayment for Lab Services in an In-Network Outpatient Hospital.  
 
  You have been asked to pay a $35 copayment for the laboratory services. The laboratory services falls within 
the Outpatient hospital 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 
the laboratory services provided on August 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interlaminar epidural steroid injection (ESI) at a 
second spinal level. 
 
You asked the Plan to pre-approve the second level of interlaminar ESI. You say that it is felt that the enrollee 
would benefit from an ILESI at the L3-L4 and L4-L5 levels. The Plan denied your request. The Plan says the 
enrollee has been approved for an ILESI of a single spinal level as this is the limit that is considered medically 
necessary in a single session. 
 
The Plan must follow Medicare rules. Medicare rules say that it is only reasonable and necessary to perform an 
ILESI at a single spinal level in one session.  
 
We looked at the file and Medicare rules. You have requested this type of injection at two levels during the 
same session. This is not considered medically reasonable and necessary under Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of the second level of interlaminar ESI have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an interlaminar epidural steroid injection 
(ESI) at a second spinal level.