Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient consultation services provided to the enrollee on 
July 11, 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 claim should be resubmitted with a more appropriate code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99255 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code 99255 is not valid for Medicare purposes. 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 
inpatient consultation services provided to the enrollee on July 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit and a consultation with an oncologist 
(99215, 99245) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit and a consultation with an oncologist. You say that the 
enrollee and her immediate family members have decided they feel comfortable receiving care from the 
requested provider and facility. The Plan denied your request. The Plan says the enrollee must receive her 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 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/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit and a consultation with an oncologist (99215, 99245) to be provided by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the osteogenesis stimulator, electrical, non-invasive, 
spinal applications (E0748) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the osteogenesis stimulator. You say that you are appealing the pre-
authorization denial of the Spinalogic Bone Growth Stimulator for this enrollee. The Plan denied your request. 
The Plan says enrollees must receive their medical services from an in-network provider with the exception 
being urgent or emergent services. Non-emergent services with non-contracted providers require prior 
authorization before services being rendered. 
 
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/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the osteogenesis stimulator, electrical, non-invasive, spinal applications (E0748) to be provided by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty, extra wide hospital bed with weight 
capacity greater than 350 pounds, but less than or equal to 600 pounds (E0303). 
 
You asked the Plan to pre-approve a hospital bed. You say that the enrollee was approved for a regular bed 
(E0260) but is very uncomfortable as he is 6'5 inches tall. The Plan denied your request. The Plan says the 
enrollee is weighs 200 pounds and does not meet the criteria for a heavy-duty hospital bed. 
 
The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary 
when at least one of the following criteria is met: 
 
1. The patient has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate 
pain; or 
 
3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to 
congestive heart failure, chronic pulmonary disease, or problems with aspiration.  Pillows or wedges must have 
been considered and ruled out; or 
 
4. The patient requires traction equipment, which can only be attached to a hospital bed. 
 
We looked at the file, and Medicare rules. The records show that the enrollee weighs 200 pounds. Based on this 
information, we decided that Medicare rules for coverage of a hospital bed have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a heavy duty, extra wide hospital bed with weight capacity 
greater than 350 pounds, but less than or equal to 600 pounds (E0303).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a vascular study duplex scan (93979) provided on March 26, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the vascular study duplex scan. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they 
were non-emergent and prior 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 a vascular study duplex scan (93979) provided on 
March 26, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for inpatient hospital care provided on 
November 23, 2021. 
 
You asked the Plan to waive the coinsurance for the inpatient care. You say that you are questioning the 
amount paid by the Plan. 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 10% 
coinsurance for each inpatient stay.  
 
You have been asked to pay $673.11, which is less than 10% of the allowed amount for the inpatient care 
($11,227.84 allowed amount x 10% coinsurance = $1,122.78). Please note that the amount is lower due to 
meeting your out-of-pocket maximum of $1,250 for the year. The inpatient care falls within the Inpatient 
Hospital 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 coinsurance for inpatient hospital care 
provided on November 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for a primary care (PCP) 
office visit and testosterone injection provided on March 7, 2022. 
 
You asked the Plan to waive the copayment and coinsurance for the office visit and injection. You say that 
primary care visits should be $0. The Plan denied your request. The Plan says the correct copayment and 
coinsurance were 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 $5 
copayment for each in-office PCP visit. 
 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for Part B drugs. 
 You have been asked to pay a $5 copayment for the office visit. The office visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. You have also been asked to 
pay $1.04 for the injection, which is 20% of the allowed amount ($5.20 allowed amount x 20% coinsurance = 
$1.04). The injection falls within the Medicare Part B Prescription Drugs benefit category. The total for the 
visit is $6.04. 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 and coinsurance for a primary care (PCP) office 
visit and testosterone injection provided on March 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a myocardial perfusion imaging (SPECT) 
provided on October 27, 2021. 
 
You asked the Plan to waive the copayment for the SPECT imaging. You say that you feel the copayment is 
too high. 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 $175 
copayment for each advanced radiology service, such as SPECT imaging.  
 
You have been asked to pay a $175 copayment for the SPECT imaging. The SPECT imaging 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 myocardial perfusion imaging (SPECT) provided on October 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213), strapping of ankle and/or foot 
(29540), and the x-ray of foot (73630) provided on March 9, 2022, by an out-of-network (OON) podiatrist. 
 
You asked the Plan to pay for the office visit, strapping, and x-ray. You say that there was a mistake by the 
front desk secretary, as they were supposed to obtain prior authorization. The Plan denied your request. The 
Plan says the services were provided out-of-network and were not 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 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 office visit (99213), strapping of ankle and/or 
foot (29540), and the x-ray of foot (73630) provided on March 9, 2022, by an out-of-network (OON) podiatrist.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management (99239) provided on 
July 3, 2021. 
 
You asked the Plan to pay for hospital discharge management. You say that this service was billed 
appropriately. The Plan denied your request. The Plan says this service is not supported in the medical records. 
 
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, the time spent providing this 
service is not noted in the record. Without this information, it cannot be verified that discharge care was 
provided for 31 or more minutes on the date in question. Based on this information, we decided that Medicare 
rules for coverage of hospital discharge management have not been met. Therefore, we decided that the Plan 
does not have to pay for hospital discharge day management (99239) provided on July 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upright walker. 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules say that a standard walker is covered when specific criteria are 
met. 
 
We looked at the file and Medicare rules. The requested item is an upright walker. This item is not a standard 
walker. Therefore, we decided that the Plan does not have to pre-approve an upright walker.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the LTACH services 
because the enrollee meets the Medicare guidelines on admission. The Plan denied your request. The Plan says 
the enrollee is not medically stable to transfer to another level of care and their needs may be met in a hospital 
setting. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where he/she is currently receiving care. All medically necessary care is being provided in the 
current acute care setting.  
 
  There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the health plan. The health plan has approved ongoing care in the current acute care 
setting.  
 
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power operated vehicle, Scooter Jazzy Evo 613 
(E1399) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the power scooter. You say that you are requesting reconsideration as you 
have stage 4 bone cancer and not lung cancer as stated on the denial letter. The Plan denied your request. The 
Plan says enrollees must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 
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/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services.  Therefore, we decided that the Plan does not have to pre-approve the power operated vehicle, Scooter Jazzy 
Evo 613 (E1399) 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 hospital observation on January 01, 2022, 
January 05, 2022. 
 
You asked the Plan to waive the copayment for hospital observation. You say that you want to appeal the 
amount being charged to you. The Plan denied your request. The Plan says the cost-sharing you are being 
charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $335 
copayment for outpatient hospital observation services. Observation services are hospital outpatient services 
given to determine if you need to be admitted as an inpatient or can be discharged.  
 
You have been asked to pay a $335 copayment for hospital observation. Hospital observation falls within the 
Outpatient hospital observation 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 
hospital observation on January 01, 2022, January 05, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463), visual field 
examination (92083), and the scanning computerized ophthalmic diagnostic imaging (92133) provided on April 
1, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient visit, vision exam, and ophthalmic diagnostic imaging. The Plan 
denied your request. The Plan says the services have been provided out-of-network and were not 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 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 hospital outpatient clinic visit (G0463), visual 
field examination (92083), and the scanning computerized ophthalmic diagnostic imaging (92133) provided on 
April 1, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard, power wheelchair and accessories 
(K0861, E2311, E2377, E2313, E2361, E1007, E1028x2, E0955, E1012, E2603). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the enrollee can only walk 
10 ft with a walker before pain starts and without a walker, he is a fall risk. He is unable to use a manual 
wheelchair due to his chronic pain in his arms and shoulders. The Plan denied your request. The Plan says the 
submitted records do not indicate a neurologic condition, myopathy, or congenital skeletal deformity. There are 
no documented problems performing mobility-related activities of daily living (MRADLs). The Plan also says 
there are no physical examination findings showing decreased upper extremity strength or an inability to 
ambulate. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
group 3 standard, power wheelchair and accessories (K0861, E2311, E2377, E2313, E2361, E1007, E1028x2, 
E0955, E1012, E2603).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional meal benefit plan. 
 
You asked the Plan to pre-approve an additional meal benefit. You say that you need an additional 3 weeks of 
meal assistance as you are wheelchair bound and cannot afford the private pay option. The Plan denied your 
request. The Plan says you have received the maximum of 14 meals for the year. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked the file and Medicare rules. Specifically, you have exceeded the 14 meals for the year. Based on 
this information, we decided that Medicare rules for coverage of additional meal benefit have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an additional meal benefit plan.